statements working together,...annual report summary financial statements 2011/12 have your say...

AnnuAl RepoRtSummARy FinAnciAl StAtementS2011/12

HAVE YOUR SAYFOUNDATION TRUST CONSULTATION DOCUMENT JANUARY - MARCH 2012

working together,

developing together.

FT Consultation Document FINAL.indd 1 11/01/2012 13:44

CONTENTS

operating and Financial Review .................................................................................................4

1. A welcome from our chair and chief executive ................................................................5

2. About our organisation .......................................................................................................6

2.1 our trust .........................................................................................................................6

2.2 Vision, Values and Strategy ...........................................................................................8

3. Highlights of the year ........................................................................................................11

4. Directors’ reports ................................................................................................................13

4.1 medical Director’s Report ............................................................................................13

4.1.1 infection prevention and control .....................................................................14

4.1.2 Research and Development ..............................................................................14

4.1.3 pharmacy ............................................................................................................15

4.1.4 clinical Audit ......................................................................................................16

4.2 Director of nursing and Allied Healthcare professionals ..........................................17

4.2.1 model of care consultation ..............................................................................17

4.2.2 West midlands Quality Review ........................................................................18

4.2.3 Back to essentials ...............................................................................................20

4.2.4 patient and public involvement (ppi) ...............................................................22

4.2.5 Safeguarding ......................................................................................................23

4.2.6 clinical Governance and Quality ......................................................................23

4.2.7 performance against the commissioning for Quality and innovation

(cQuin) Framework ...........................................................................................24

4.3 Director of leadership and Workforce .......................................................................26

4.3.1 Human Resources ..............................................................................................26

4.3.2 organisational Development ............................................................................31

4.3.3 Wellbeing counselling ......................................................................................34

4.3.4 training ...............................................................................................................35

4.3.5 leadership Development ..................................................................................35

4.4 Director of Finance and performance .........................................................................36

4.4.1 performance against Key performance indicators (Kpis) ................................36

4.4.2 Finance ................................................................................................................37

5. Working with our partners ................................................................................................39

5.1 Building involvement with our Service users and carers .........................................39

5.2 patient Stories ..............................................................................................................40

5.3 Gp associate appointments .........................................................................................40

5.4 Ft and membership .....................................................................................................40

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6. Governance .........................................................................................................................43

6.1 Registration Regulations 2011/12 ............................................................................43

6.2 estates including Sustainability Report ...................................................................44

6.3 emergency planning .................................................................................................47

6.4 Risk management .....................................................................................................47

6.5 information Governance ..........................................................................................49

6.6 equality, Diversity and Human Rights .....................................................................50

6.7 complaints and compliments ..................................................................................51

6.8 Freedom of information 2000 Act requests (Foi) ...................................................53

6.9 Serious incidents (Sis) ...............................................................................................53

6.10 local counter Fraud Service .....................................................................................54

6.11 trust Auditors ............................................................................................................54

7. our trust Board...................................................................................................................57

7.1 Details of our Directors ...............................................................................................57

7.2 Details of our Directors’ declared private interests...................................................58

8. Remuneration Report .........................................................................................................59

8.1 Remuneration of Senior managers – Salaries............................................................61

8.2 Remuneration of Senior managers - pensions Benefits............................................63

8.3 exit packages Disclosure ..............................................................................................64

9. Summary Financial Statements for the period 1st April, 2011 to the

31st march, 2012 .................................................................................................................65

9.1 introduction to Financial Statements 2011/12 ...........................................................65

9.2 Statement of comprehensive income for the year ended 31 march 2012 ......................68

9.3 Statement of Financial position as at 31 march 2012 .......................................................69

9.4 Statement of cash Flows for the year ended 31 march 2012 ..........................................70

9.5 notes to the Summary Financial Statements .....................................................................71

9.6 Statement of Accounting officer’s Responsibilities ..........................................................72

9.7 Statement of Directors’ Responsibilities in Respect of the Accounts ..............................73

9.8 independent Auditor’s Report to the Board of Directors .................................................74

10. nHS Government Statements (formerly Statement of internal control) ........................77

Appendix 1 – Glossary ...............................................................................................................91

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Operating and Financial Review

The Operating and Financial Review is spread throughout Sections 7-9 of the Annual Report and

Summary Financial Statements.

This document may not contain sufficient information for a full understanding of the Trust’s

financial position and performance.

A copy of the Trust’s full accounts can be obtained by contacting the Trust Secretary in writing, or

by telephone at:

Mrs S Storey, Trust Secretary

Harplands Hospital

Hilton Road

Harpfields

Stoke on Trent

ST4 6TH

Tel: 01782 275105

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5

Fiona myersChief Executive

mr Ken Jarrold cBe

Chairman

North Staffordshire Combined Healthcare NHS Trust Annual Report

A Welcome from our chairman and Chief Executive

The Trust had a difficult financial agenda including a very demanding cost improvement target. 97% of the target was delivered and financial balance was achieved. Everyone in the Trust is to be congratulated on this achievement.

The proposals in the Health and Social Care Bill, now an Act, are the most radical reorganisation in the history of the NHS. We prepared for the implementation of the Act by developing relationships with the Clinical Commissioning Groups and the Primary Care Trust (PCT) Cluster.

It is vital that we work closely with commissioners and are responsive to their reshaping and planning of services. The appointment of two GP Associates to our Board provides valuable insight and a close link to our colleagues in primary care.

We continued with our journey towards becoming an NHS Foundation Trust and carried out a successful public consultation process, seeking views on the detailed arrangements for our Council of Governors.

There were changes in Board membership, including a new Chair, two new Non Executive Directors and two new Executive Directors.

2010/11 was an important year of service change. We consulted on the Phase 1 proposals which resulted in agreement to close Bucknall Hospital and to transfer services to more appropriate locations.

We have come to understand, more clearly than ever, the overriding importance of quality and of working closely with service users and carers.

We have also deepened our understanding that the Trust is only one of the providers of services for people with mental illness and learning disability and that working in partnership with our close colleagues, in other statutory agencies and in the voluntary and community sector, is vital to the well being of the people we all serve.

2010/11 was a very difficult year. The NHS faced two major challenges:First, the tight financial position coming after the years of growth; and second, the preparations for the implementation of the Health and Social Care Bill.

2. About our organisation

North Stafforshire PCT

Bucknall Hospital

Stoke-on-Trent PCT

Newcastle-under-LymeDistrict

• Ashcombe Centre

Leek

• Greenfield Centre

Bradwell Hospital • Lymebrook

Harplands Hospital• Ashlands Centre

• Bennett Centre & Richmond Terrace

• Darwin Centre

• Sutherland Centre

South Stafforshire PCT

Central and EasternCheshire PCT

Congleton

Crewe

Stoke-on-Trent

Bucknall Hospital

Stoke-on-Trent PCT

• Greenfield Centre

Harplands Hospital• Ashlands Centre

• Bennett Centre & Richmond Terrace

• Darwin Centre

• Sutherland Centre

We employ over 1,900 staff and our turnover for 2011/12 was just over £83 million. We provide mental health services from just over 30 sites - our main site being a private finance initiative (PFI) facility located at the Harplands Hospital which opened in 2001 and which provides the setting for most of our

inpatient units. Service delivery is supported by five resource centres spread across the county which provide step up and step down alternatives for acute hospital admission and a children’s and adolescent inpatient unit, all shown on the map below:

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Working to improve the mental health and wellbeing of local communities

2.1 our trust

north Staffordshire combined Healthcare nHS trust was established in 1994 following the merger of four directly managed units, providing adult and older people mental health, learning disability, and primary care services.

In addition to our inpatient services, we provide the following:

• Crisis resolution and home treatment support through our community teams.

• Specialist mental health services which include inpatient drug and alcohol services; liaison psychiatry; community mother and baby services; mentally disordered offenders and psychological therapies.

• Child and adolescent mental health services including community tier 2 and 3 services.

• Neuropsychiatry services. • Organic older people’s mental

health services.• Learning disability services

provided in both hospital and community settings.

The Trust manages its services through three clinical divisions, shown below:

• Adult Mental Health• Children and Adolescent Services• Learning Disability,

Neuropsychiatry and Old Age Psychiatry

Each division is headed by a Clinical Director supported by a Business Manager. Within each Division, clinical leads champion clinical excellence for the specialty. This divisional structure was adopted following a review based upon the introduction of service line management principles to the organisation.

In addition to our clinical services, we provide shared services (health informatics, information technology, estates and health and safety) to NHS Stoke-on-Trent and NHS North Staffordshire. We also purchase some therapy services from NHS North Staffordshire; finance agency services from NHS Stoke-on-Trent, and hold agreements for both clinical and non-clinical services with the University Hospital of North Staffordshire NHS Trust.

We provide a growing research and development programme in collaboration with local and regional research networks – extending the role of this function features in our plans for the future including building on current infrastructure to continue to deliver high quality research across a wide range of mental health topics.

We work in partnership with a range of educational establishments to support staff training. These educational links raise the profile of our Trust, help the wider healthcare community to improve mental health and learning disability services and ensure that our staff keep up to date with best practice. Our research and education partners are:

• The West Midlands Workforce Deanery.

• University of Keele Medical School.

• Keele University. • Staffordshire University.

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Financial Strategy

Workforce Strategy

Estate Strategy

Innovation Strategy

Governance Strategy

Customer Focus

Strategy

IM&T Strategy

our strategic goals• To deliver high quality person centred models of

care, throughout the organisation.

• To be at the centre of an integrated network of partnerships to provide a holistic approach to care.

• To engage with our communities to ensure we deliver the services they require.

• To be a dynamic organisation driven by innovation.

• To be one of the most efficient providers.

our vision• To provide patient centred mental

health, specialist learning disability and related services for people of all ages.

• To be the best in all that we do.

• To work in partnership to deliver services that promote recovery, wellbeing and independent living.

our values• Valuing people as individuals.

• Providing high quality innovative care.

• Working together for better lives.

• Openness and honesty.

• Exceeding expectations.

our purpose: Working to improve the mental health and wellbeing of local communities

clinical Strategy

2.2 Vision, Values and Strategy

Our core purpose is to improve the mental health and wellbeing of our local communities – some 464,000 people living across Stoke on Trent and North Staffordshire. Our strategy is to deliver an evidence based model of care, which is appropriate to our service user needs and focuses on wellbeing and on-going recovery. We aim to be

recognised as a centre of excellence, bringing innovative solutions to the services we deliver and embedding a culture of continuous learning across our organisation.

This is reflected in our strategy, vision and values and underpinned by a number of enabling strategies, shown in the diagram below:

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Delivering our strategy will mean our service users feel empowered to manage their own mental health and they will have a care pathway that is clearly signposted through services provided both by us and our partner organisations.

In 2011, new Trust values were developed by staff for staff, to help provide a common understanding of what we are about a base against which we can all work.

those values are:

• Valuing people as individuals• Providing high quality innovative

care• Working together for better lives• Openness and honesty• Exceeding expectations

A tool was developed to assist staff in having conversations about the values, with the aim of stimulating discussions around what the values mean to individual teams, understanding areas of good practice and the areas which challenge us.

One of the strongest messages that came out of the values development work was that Trust staff wanted these values to be real, to be shared and lived and to be used to guide our behaviour, actions and decisions. The development of the logo and a ‘Team Conversations’ tool is only one part of that process – through openly displaying, sharing and discussing our values, together we can move one step closer to becoming an organisation that is truly values-led.

April 2011• OpeningMinds–Early

Intervention at Newcastle Borough Museum and Art Gallery

• AppointmentoftwoGPAssociates

May 2011• StaffordshirePoliceAwards-

Local Section 136 Group• StrokeOxygenStudy

June 2011• FallsAwarenessWeek• Formerpatient/Stoke-on-

Trent College Bench donation

July 2011• DementiaAwarenessWeek

Memory Clinics

August 2011• PhaseOneconsultation

launched

September 2011• AnnualGeneralMeeting

(AGM)• IntroductionofRapid

Assessment Interface and Discharge (RAID) service

• MysteryShopperlaunched

October 2011• WorldMentalHealthDay• ServiceUsers’artwork

displayed in Harplands Reception

November 2011• OccupationalTherapyWeek• EuropeanAntibiotic

Awareness Day with a New Record

• AlcoholAwarenessWeek

December 2011• NewChairappointed

January 2012• FoundationTrustapplication

public consultation launched• HealthandWellbeingevent

February 2012• CommunityMentalHealth

Survey launched

March 2012• HIGHLIGHTOFTHEYEAR

Staff Reach Awards

More detailed information on all the year’s news can be found in the Annual Review, available on request from the Communications Team

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3. Highlights of the Year

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4. Directors’ reports


the management of the trust is headed by its Board of Directors, made up of:

4.1 medical Director’s Report

The Trust’s Medical Director is Dr Buki Adeyemo. She was appointed to the post in January 2012. The former Medical Director, Dr Mike Jorsh, who is one of the few recognised liaison consultants within the West Midlands region, stepped down from the role to concentrate on the development of the Trust’s RAID liaison services, to support the local health economy requirement of reducing bed-based services and to progress integration with more services in the community.

Dr Adeyemo is a qualified consultant in old age psychiatry, and has worked in the NHS for 14 years, the majority of that time in North Staffordshire. During her career, Dr Adeyemo has specialised in medical education and psychological therapies.

She has completed a Post-Graduate Certificate in Medical Education and Interpersonal Therapy Level B and she now works with trainee doctors, medical students and healthcare staff, advising and preparing them for professional qualifications.

• Executive Medical Director

• Executive Director of Nursing and Allied Healthcare Professionals

• Director of Leadership and Workforce

• Executive Director of Finance and Performance

• Chief Operating Officer

and supported by:

• Trust Secretary / Head of Corporate and Legal Affairs

Dr Buki Adeyemo Dr Mike Jorsh

Throughout 2012/12, the Medical Directors’ responsibilities included:

4.1.1 Infection Prevention and

Control

Department of Health guidance including ‘Equity and excellence: Liberating the NHS’ and the ‘Operating Framework for the NHS in England’ refer to improving outcomes. Listed in the five national priorities is improving cleanliness and reducing healthcare associated infection. The Trust is also aware of the duty placed upon it by The Health and Social Care Act 2008 Code of Practice on the prevention and control of infection and related guidance (Department of Health 2010).

Not all infections can be prevented; however the Trust is committed to minimising the risk of infection and has a zero tolerance approach to avoidable infections. The published ‘Annual Programme of Work’ documents the actions taken to enhance systems and procedures and to strengthen the Trust position in assessing compliance with key national documents.

We are proud to report a sustained, year on year reduction in healthcare associated infections. There have been no MRSA infections since 2007 and, during 2011/12, we reported one Clostridium difficile infection (CDI). Statistically this represents a 50% improvement on reported CDIs in the previous year.

In 2011 the requirements for mandatory reporting were extended to include Meticillin sensitive Staphylococcus aureus (MSSA) and Eschericia coli (E.coli) blood stream infections. The Trust reported one MSSA and one E.coli infection. Selective MRSA admission screening has been

undertaken throughout the year, in accordance with national guidance for mental health organisations. Positive cases are offered the MRSA decolonisation regime.

During the course of the year, outbreaks of Norovirus resulted in the temporary closure of three wards and one learning disability bungalow. Strict control measures, including enhanced cleaning, were implemented and all outbreaks were contained in the affected area. The number of outbreaks is comparable to previous years and all were managed to minimise the impact upon service delivery.

High standards of cleanliness have been maintained across the Trust with scores of excellent or good being reported. Further details can be found in the Trust’s Infection Prevention and Control Annual Report 2011/12.

4.1.2 Research and

Development

Offering patients an opportunity to take part in high quality research projects continues to be a high priority for North Staffordshire Combined Healthcare NHS Trust.

Research and Development (R&D) activity within the Trust is managed in-house, by the Research and Development Department, a relatively new Department, formed in 2008. During 2011/12 the team recruited 684 patients and members of staff into National Institute for Health Research (NIHR) projects across many specialties within the Trust. We have already achieved the Department of Health target to double the number of participants recruited into NIHR studies by 2014.

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Our main research areas of interest are as follows:

• Dementia

• Huntington’s Disease

• Schizophrenia

• Learning Disability

• Attention Deficit Hyperactivity Disorder (ADHD)

• Addictions

• Mood Disorders

• Psychosis

• Mental Health and Ageing

• Stroke

We work closely with a number of NIHR networks including:

• Mental Health Research Network (MHRN)

• Dementias and Neurodegenerative Diseases Network (DeNDRoN)

• West Midlands Stroke Research Network (WMSRN)

• West Midlands North Comprehensive Local Research Network (WMNCLRN)

Key areas of work over the year have been:

• The continued recruitment to NIHR portfolio studies and being selected as a site for new portfolio studies. The number of commercial studies has also increased and we are now participating in a commercial clinical trial and assessing feasibility on a number of other clinical trials.

• We have continued to increase the number of staff as a member in the ‘interested researchers’ email grouping, Good Clinical Practice (GCP) training sessions and research open days. We are

engaging staff in undertaking research and developing their own research ideas. We now have a total of 63 staff trained in GCP

• Maintaining and building links with the Mental Health Research Network (MHRN), Dementias and Neurodegenerative Diseases Research Network (DeNDRoN), Quintiles (Commercial clinical research organisation), patient and public involvement and South Staffordshire and Shropshire Mental Health Trust.

• A successful £1.4 million application for the Stroke Oxygen Study, of which the Trust is Sponsor

4.1.3 Pharmacy

Previously, the Trust had provided pharmacy services to a number of local PCT-led hospitals, under an informal arrangement. 2011/12 saw the handover of these services, provided at Bradwell, Cheadle and Leek hospitals, to the Haywood Hospital pharmacy team.

The service has continued to work on and raise awareness of medicines issues including:

• Patient and carer information available on Choice and Medication website

• Review of medicine related incidents

• Introduction of pharmacy assessments for dispensing accuracy and for pharmacists ‘checking’ accuracy

• Introduction of a new Nurse Administration Assessment across all in-patients areas.

• A series of training events as part of Making Every Dose Safe within the Back to Essentials campaign

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Each month, the NSCHT Pharmacy Service dispenses around 6,500 prescriptions from the dispensary at Harplands Hospital. This services is for in-patients as well as for service users who require a regular supply of specific medicines as out-patients.

4.1.4 Clinical Audit

During the year, a total of 83 projects were completed.

16 projects were completed in line with national requirements / standards, including National Institute for Health and Clinical Excellence (NICE) guidance, Prescribing Observatory for Mental Health (POMH) and standards produced by the Royal Colleges.

20 projects were conducted that contributed to the achievement of performance indicators and CQUIN targets however it should be noted that for many of these (n) projects, data was collected, analysed and reported on a quarterly basis.

All projects on the clinical audit programme were managed by the Clinical Audit Department. The Clinical Audit programme for the Trust was approved by the Quality and Governance Committee, the Trust Clinical Effectiveness Group (TCEG) and Divisional Management Meetings and interim reports were provided during the year.

On completion of each project, the results are fed back to the steering groups through draft reports and presentations. Action plans for improvement are developed for each project by the steering groups and incorporated into the final report. Copies of project reports were distributed widely to staff,

including Executive Directors and Divisional / Business / Operational Managers.

The Clinical Audit Department also provided support and advice covering all stages of the clinical audit cycle. This year the team has designed a number of projects to be undertaken by the junior doctor rotation and have supported staff members undertaking their own projects.

A selection of some of the topics covered in completed clinical audits includes:

• National Audit of Schizophrenia

• Patient Experience – Community Based Services and Hospital Based Services

• Carer Experiences

• Safer Care – Use of Trigger Tools

• Planned and Effective Discharge – Improved Discharge Planning

• Dementia

• Improved Transition Planning for ChildrenandYoungPeople

• Dual Diagnosis (Alcohol)

• Accommodation, Employment and Smoking

• Nutritional Assessments and Satisfaction with Trust Catering Services

• Physical Health Monitoring

• Antipsychotic medication

• Health Records and Documentation

• Sections relating to the Mental Health Act

• Trends Arising from Serious Incidents

• Medicines Management and Pharmacy Services


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4.2 Director of nursing and Allied Healthcare professionals

During 20111/12, the Trust’s Director of Nursing and Allied Healthcare Professionals was David Pearson, MBE. Mr Pearson retired in 2012 with over 39 years service.

Between 1997 – 2000, David played a major role in closing St Edward’s hospital and re-engineering local mental health services in line with National Service Framework standards. In 1997, David was appointed Clinical lecturer to Keele University’s department of post graduate psychiatry and in 2005 made a visiting fellow in mental health nursing at Staffordshire University.

David held the role of Director of Nursing and Allied Healthcare Professionals from October 2001 and was responsible for professional issues affecting nursing including the advancement of nursing practice and the training and development of nurses.

Mr Steve Gregory joined the Trust in February 2012, to ensure a seamless handover of the post, working alongside Mr Pearson

until his retirement date in May 2012. The Director for Nursing and Allied Healthcare Professionals is responsible for the following areas:

4.2.1 Model of Care Consultation

In 2011 the Trust, together with cluster commissioners, launched the Model of Care Service Redesign programme, with the intention of changing the way in which a number of clinical services are delivered. These changes, based on clinical evidence and national recommendations, required public consultation and included:

• Dementia services transferring from Bucknall to Harplands Hospital

• Support for older people experiencing periods of feeling mentally or emotionally unwell taking place via enhanced community teams, ensuring people are supported in their own homes.

• Rehabilitation care being provided in more appropriate community settings.

• Use of Resource Centres

• Use of Older People’s services Day Hospitals.

Mr David Pearson MBE Mr Steve Gregory

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The Trust decided, on listening to feedback from its stakeholders and service users, to address the public consultation in two stages – Phase One and Phase Two.

The Phase One public consultation launched in August 2011 after extensive engagement with stakeholders, culminating in approval to proceed with the consultation from local commissioners (both Primary Care Trusts [PCTs] and the two clinical commissioning groups [CCGs]), the four local overview and scrutiny committees, Office of Government and Commerce Gateway reviewers, the National Clinical Advisory Team and the Strategic Health Authority (SHA).

The consultation ran for 12 weeks until the end of October 2011 and the outcome allowed the Trust to make changes to dementia services, older people’s services, community services and rehabilitation care. This also resulted in the Trust moving towards the closure of its 100-year-old Bucknall Hospital site, where the out-dated buildings were no longer suitable for modern healthcare, and the location was isolated, particularly from the Trust’s Harplands Hospital in Hartshill and the local communities it serves.

The Trust engaged the independent Local Involvement Network (LINk) to evaluate the decision-making process undertaken throughout the consultation. The LINk concluded that the process undertaken was fair and thorough.

Following this assessment, the Trust Board, CCGs and Cluster signed off the scheme which has now moved to full implementation overseen by a programme management support team. The implementation plans have been assessed through the Gateway review process scoring an amber green rating.

Phase Two, which will take place in 2012/13, considers further changes to the model of care within Adult and Older People’s mental health services, predominantly focusing on Adult Mental Health (AMH) inpatient wards at Harplands, the resource centres and Older People’s Mental Health (OPMH) day services.

4.2.2 West Midlands Quality Review

The West Midlands Quality Review Service (WMQRS) visited the Trust in October 2011. The purpose of the visit was to review compliance with WMQRS Quality Standards for:

• Mental Health Services

• Health Services for People with Learning Disabilities

• Dementia Services

The review also included care of Vulnerable Adults in Acute Hospitals and therefore included review of relevant services at the University Hospital of North Staffordshire.

The purpose of these standards and the review programme is to help providers and commissioners of services to improve clinical outcomes and service users’ and carers’ experiences.


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The review of North Staffordshire health economy found good integration of health and social care throughout commissioning and provider organisations. Section 75 agreements were in place and issues of transfer of social care staff to health organisations had been well worked through. Staff in all organisations were committed to reducing stigma and a greater focus on recovery. Relationships between organisations were good at an operational level, although often dependent on long-standing personal relationships. Partnerships with stakeholders were well-established and were maintained through a range of forums. Good service user and carer engagement was evident throughout the review with particularly good input from the North Staffs User Group. This group was funded by the PCTs and the local authority, and provided with accommodation at a variety of bases around North Staffordshire. A carers’ group was also running. There was a well-regarded carer support service with robust procedures for offering assessments of carers’ needs. Good

arrangements for determining service user satisfaction were in place with a positive relationship with PALS and LINks.

A report was produced which provided the Trust with an opportunity to produce an Action Plan to address areas for improvement. These included:

• IT systems for managing and recording information about service users’ care

• Access to paper-based clinical records and ease of storage access

• improving links between services and ways to improve pathways for service users, especially where this would contribute to their recovery

The Action Plan was drawn up in late 2011 and is a key priority for the Trust during 2012/13, monitored through the Quality and Governance Committee. Implementation of an improved Access service and the introduction of RAID services in UHNS have already impacted positively on areas outlined in the report.

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4.2.3 Back to Essentials

Whilst there is evidence of excellent work undertaken by many highly skilled staff within the Trust, the challenge remains to make sure that all clinicians and services are achieving consistently high standards. Consistent themes have emerged from both national reports and investigations into local serious untoward incidents. There is a need to provide assurances to the Board, Commissioners, local communities and most of all our patients, that Trust services are safe, sound and supportive.

The Trust has introduced the Back to Essentials Campaign around seven Domains of Essential Care to support Patient Safety, Patient Experience and Effectiveness of Care:

1 Person centred care – ‘nothing about me without me’

2 Physical healthcare – ‘care aware’

3 Safeguarding – ‘do no harm’

4 Medicines management – ‘MEDS’ (make every dose safe)

5 Record Keeping & risk management - ‘if not recorded it never happened’

6 Legal Compliance – ‘RISKS’ (responsible, informed, safe & knowledgeable services)

7 Communication – RULE (respond, understand, listen, effectively)

During the year, we have held a number of events to work through each of the domains to:

• Map existing care processes

• Analyse where problems exist and critically question the process

• Imagine what an ‘ideal’ process might look like

• Identify what support / advice is available

• Identify what practical changes need to be made to the current process to bring it closer to the ‘ideal’.


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Some early successes:

• Revision and re-introduction of annual assessment for nursing staff in the administration of medicines.

• Identification of metrics that promote the nursing contribution to quality around person-centred care.

• ‘Values’ based risk assessment training introduced.

• Introduction of a clinical skills facilitator

next steps

• Further engagement of multi professional team

• Further involvement of service users and carers

• Embedding campaign

• Sustainability

• Efficiency versus Effectiveness

• Evaluation

• Wider promotion

Where are we now?

• Six of the seven domains have been delivered and actions / indicators have been agreed

• Logos and strap lines for each of the domains and other promotional materials have been produced:

4.2.4 Patient and Public

Involvement (PPI)

The Trust has continued to develop its Patient Experience Strategy and build on work with service users, carers and local representative groups to feedback about their experiences of using our services, to inform service improvement. The strategy includes key objectives with supporting actions, including:

• Gathering feedback – increasing sources and types of feedback

• Learning from feedback

• Information – the right information at the right time

• Increased staff involvement and awareness – personal responsibilities in support of improvement

• Leadership – Improving the patient experience is everybody’s responsibility

• Improvement at every opportunity – via the Back to Essentials Campaign

• Intelligent use of feedback and monitoring – identifying a central promoting early identification of emerging themes and trends

• Feeding back to patients and stakeholders – Increased opportunities. During 2011/12, a key objective of the Strategy was

to introduce quarterly patient experience summary reports. These have been successfully developed and reported on throughout the year. Summary reports include:

• A summary of feedback activity undertaken across each division

• Early identification of emerging themes or trends

• Suggested recommendations and actions

• Compliments

Some of the emerging themes and trends have been identified via analysis of data taken from our inpatient discharge questionnaire. These include:

• A summary of feedback activity undertaken across each division

• Early identification of emerging themes or trends

• Suggested recommendations and actions

• Compliments

Some of the emerging themes and trends have been identified via analysis of data taken from our inpatient discharge questionnaire. These include:

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Care planning When you were discharged, were you offered a copy of your discharge care plan?

Activities During your stay, were there enough activities available to for you to do

Information When you arrived on the ward were you given enough information about your stay on the ward?

Medication Did staff clearly explain the side effects of medication in a way that you could understand?

Family and Home Situation As far as you know, did hospital staff take your family or home situation into account?

Care and Treatment Were you involved as much as you wanted to be in decisions about your care and treatment?

Working for the health & wellbeing of our local communities

Scoring Symbol

5% and above increase in score

Less than 5% change in score

5% or more decrease in score

4.2.5 Safeguarding

The Trust is committed to ensuring that all people who come into contact with our services are safeguarded from abuse in line with local and national policy.

Safeguarding Surveillance

The Trust has made significant improvements in relation to safeguarding surveillance systems throughout 2011/12. These improvements enable the organisation to monitor trends and themes of safeguarding incidents. This in turn enables the Trust to act early in order to reduce incidents of harm.

Safeguarding training

Safeguarding training is a mandatory requirement for all Trust employees. There is a rolling programme of training events available to ensure that all staff have access to safeguarding training.

Safeguarding Supervision

In order to meet the standards required in relation to safeguarding vulnerable people, the Trust acknowledges that an educated, supported work force is required. A Safeguarding Supervision Strategy was developed in 2011/12 which

offers four levels of supervision to all those working with vulnerable adults and children.

4.2.6 Clinical Governance and

Quality

The Trust developed a comprehensive Quality & Governance Development Plan in April 2011 which includes a whole range of actions to continue to improve the quality of the services we provide. It also provides a robust framework to manage risks associated with any gaps in performance or deteriorating trends. This is a ‘living document’ in that it is regularly updated as new actions are identified and others are delivered and implementation is overseen by the Trust’s Quality & Governance Committee.

The Development Plan has two specific sections:

• Section 1 provides an overarching coordination of all action plans in place in the Trust to improve quality, safety and governance

• Section 2 contains all key individual actions identified at clinical team, division and corporate level in response to ongoing assessments of compliance with the essential standards of quality and safety.

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A simple scoring system helps us to effectively monitor improvement trends.

In line with other NHS trusts, NSCHT produces an annual Quality Account. This is a report to the public about the quality of services we provide and demonstrates that we have processes in place to regularly scrutinize all of our services. Patients, carers, key partners and the general public use our Quality Account to understand:

• What our organisation is doing well

• Where improvements in the quality of services we provide is required

• What our priorities for improvement are for the coming year

• How we have involved services users, staff and others with an interest in our organisation in determining these priorities for improvements.

Our Quality Account can be found on the Trust’s website athttp://www.combined.nhs.uk/aboutus/performance/Pages/QualityAccounts.aspx

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4.2.7 Performance against the Commissioning for Quality and Innovation (CQUIN) Framework

‘High Quality Care for All’ included a commitment to make a proportion of providers’ income from primary care trusts conditional on quality and innovation, through the CQUIN payment framework. This is a national framework for locally agreed improvement schemes and makes a proportion of provider income conditional on the achievement of ambitious quality improvement goals and innovations. The CQUIN framework is intended to reward genuine ambition and stretch, encouraging a culture of continuous quality improvement in all providers.

We are fully engaged in this national framework and as an incentive, 1.5% (£872,474) of the Trust’s income for 2011/12 was

linked to the delivery of a number of schemes.

We have worked closely with our commissioners on nine schemes in 2011/12, achieving 91.65% of the overall target. As a result, the Trust received 99% of the overall potential income available. To support the delivery of our service improvement, our main commissioners have continued to work with the Trust via the Clinical Quality Review Group which is attended by commissioners and senior Trust clinicians.

The implementation of the individual schemes has resulted in a number of measureable improvements in the quality of services provided, even those schemes not fully delivered in terms in achieving the targets and maximum income.

The table overleaf describes the position for 2011/12


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For 2012/13, the CQUIN framework has been allocated a value of 2.5% of the Trust’s income and is made up of six schemes.

Key performance indicator (Kpi)

The green ticks indicate that all targets were met and therefore all income achieved.

The amber ticks indicate that a number, but not all, of the elements were achieved and a proportion of the available income was obtained.

commissioning for Quality and innovation Scheme (cQuinS)

Patient Experience: Measuring patient satisfaction of inpatient and community mental health services and taking action to improve satisfaction.

Carer Experience: Measuring the level of support offered to carers of mental health patients and taking action to improve carer support and carer satisfac-tion.

Safer Care – Use of Trigger Tools: Using specially designed mechanisms to contin-uously monitor the level of harm events to inpatients and use the information to prioritise safety improvement initiatives.

Safer Care – Safety Improvement Initiatives: Developing and implementing pro-grammes of work to reduce the risks arising from assaults, slips trips and falls or medication incidents.

Planned and Effective Discharge: Reviewing and improving discharge planning for all inpatients to reduce the length of stay, improve outcomes post discharge and reduce readmissions and poor outcomes after discharge.

Dementia: Ensuring the appropriate prescribing of antipsychotic medication for people with dementia and improving the discharge of patients with dementia.

ChildrenandYoungPeople’sServices:Improvingarrangementswhenapersonmoves from the services provided for children and young person’s services to adult services.

Dual Diagnosis (Alcohol): Improving effective care for patients who need sup-port for alcohol misuse and who also have mental health care needs.

Community Mental Health Services: Improving care planning and outcome measuring in community mental health services for adults and older people.

g

g

g

g

g

a

a

a

a

a

a

Caroline Donovan has held the substantive role of Director of Leadership and Workforce since June 2010 following a period of secondment from West Midlands SHA into the Trust in July 2009.

Caroline is a registered general nurse, health visitor and holds MSc and CIPD qualifications. She has broad management experience and specialist expertise in workforce and organisational development.

Her previous role was Associate Regional Director of Workforce where she was responsible for the management of the Workforce Deanery.

Caroline is responsible for the following areas:

4.3.1 Human Resources As at March 31, 2012, North Staffordshire Combined Healthcare NHS Trust employed 1,452 whole time equivalent (WTE), 1961 (headcount) staff over a range of staff positions. These figures include the social care staff who transferred into the Trust from Stoke on Trent City Council and Staffordshire County Council.

Staff costs currently amount to 75% of Trust total Income, reducing to 70.5% by 2015/16. In financial terms currently £62,262,000 is spent on staff, on Trust Income of £83,063,000

4.3 Director of leadership and Workforce

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Staff group total employees Whole time equivelant

Add Prof Scientific and Technical 138.51

Additional Clinical Services 406.42

Administrative and Clerical 262.11

Allied Health Professionals 43.50

Estates and Ancillary 88.65

Medical and Dental 53.20

Nursing and Midwifery Registered 448.02

Students 12.00

totAl 1452.41

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Our workforce profile as at March 31, 2012

18 % Administration andClerical Services

3 % Allied HealthProfessionals

6 % Estates andAncillary

4 % Medical andDental

28 % Additional Clinical Services

9 % Add Prof, Scientificand Technical

1 % Students

31 % Nursing

Our workforce profile

It is important to acknowledge that there is currently an ageing population and in light of the amendments to retirement legislation, the profile of the workforce will alter in the future. The age distribution of our workforce is very similar to the distribution for all mental healthand learning disability Trusts as shown in the graph above.

Our workforce is ageing and in the medium-term we will need to be mindful of any gaps likely to be created as post holders retire. We will build on existing recruitment approaches and where necessary

use innovative ways to attract staff, including recruiting younger staff through apprenticeships.

The gender profile of the Trust, whilst not representative of the local community, reflects the fact that the NHS is a female dominated service nationally. In April 2012 the gender split across the workforce was 73.25% female and 26.75% male and this compares regionally with 73% female and 27% male for mental health and learning disabilities Trusts.

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Age and gender profile of our workforce

20.00%

18.00%

16.00%

14.00%

12.00%

10.00%

8.00%

6.00%

4.00%

2.00%

0.00%

Un

der

25

25 -

29

30 -

34

35 -

39

40 -

44

45 -

49

50 -

54

55 -

60

Ove

r 60

% o

f W

ork

forc

e

Ageband

North StaffordshireCombined HealthcareNHS Trust

NH & LD BenchmarkGroup

Age profile of nScHt Workforce


Ethnicity profile

The ethnic composition of the workforce is comparable to the ethnic composition of the local population as shown below:

Turnover

The Trust has a turnover rate for 2011/12 of 9.21%, a figure which has dropped significantly from the 2010/11 due to the absence ofany large scale transfers of staff or

services. The average of Mental Health and Learning Disabilities Trusts within the region report a turnover rate of 14.54% (Jan 11-Jan 12)

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A Chart showing a comparison of Turnover Rates

15

10

5

0

NSCHT MH & LDBenchmark

StaffordshireCluster

Bme / White ethnic categorypercentage of

local population (2011 census)

trust Workforce

BME

Asian or Asian British 2.11% 2.04%

Black or Black British 0.31% 1.55%

Mixed 0.70% 0.39%

Other 0.33% 0.58%

Total BME 3.44% 4.6%

WhiteWhite British 95.32% 92%

White Other 1.24% 1.12%

Total White 96.56% 95.4%

Sickness absence

Steady progress has been made in reducing sickness absence over the last five years from 5.51% in 2007/08 to 4.85% in 2009/10, 4.25% in 2010/11 and 4.16% in 2011/12. This compares favourably with other mental health and learning disability trusts nationally. The Trust currently has the lowest sickness absence rate of Mental Health and Learning Disabilities Trusts in the region, with the average being reported at 5.04%

Regular sickness reports are distributed to business managers and are reported at divisional meetings. HR Business Partners support business managers in working to reduce sickness absence. Regular meetings are held between the occupational health service and HR relating to individual cases to expedite a timely and supported return to work.

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Equality and diversity

The Trust aspires to be an Equal Opportunities employer. Our aim is to ensure that all employees are not subject to any form of discrimination, harassment and/or bullying at any time on the basis of their age, gender, ethnic origin, colour, disability, illness (such as HIV or AIDS), marital status, nationality, race, religion, sexual orientation and social background. Policies are in place to support this and, in

January 2012, the Trust published its first Equality Act Compliance Report which can be accessed via the following link.http://www.combined.nhs.uk/helpadvice/Documents/Equality%20report%20Jan%202012%2029%20Jan%20FINAL.pdf

Sickness Absence Comparison for NSCHT

5.5

5

4.5

4

2009/10 2010/11 2011/12

Sick

nes

s % NSCHT

MH&LD Benchmark

Staffordshire Cluster

Sickness Absence Rates


4.3.2 Organisational Development

Staff Engagement

It is now widely recognised and evidenced that organisations with strong staff engagement generally perform better in a range of measures including: productivity, service quality and customer satisfaction.

In recognition of this wealth of evidence, in July 2011, our Trust developed and launched a Staff Involvement and Engagement Strategy, to guide its activities designed to actively improve levels of staff engagement. This strategy is based around six key strands as illustrated in our six-pointed star model as below.

One of the key strands, Listening and Responding to Staff, sets out the goal of developing a listening organisation, capable of harnessing the knowledge and experience of the workforce to simultaneously improve services and working lives. We aim to do this by:

• effective social partnership with staff side organisations

• effective direct communications to all staff through a variety of channels

• effective formal and informal channels for seeking out and understanding staff views

• demonstrating that we turn listening into action.

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measuring monitoring

learning Developing

Stand 1Living the

Values

Stand 4WorkplaceWellbeing

Stand 1Living the

Values

Stand 2Leadership

Development

Stand 5Positive

Communications& Celebrations

Stand 3Listening to

and Respondingto Staff

StaffInvolvement

& Engagement

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Performance Development Review Performance Development Review or ‘PDR’ (the Trust’s name for the appraisal process) is well-recognised as being highly important aspect of organisational life which – when well conducted – correlates strongly with enhanced organisational performance, including a variety of measures on service quality, efficiency and effectiveness.

PDR encourages staff, with their managers, to take time out from their day-to-day work responsibilities to reflect on how things have been going and where improvements could be made to the benefit of service users or other team customers. It focuses attention on how individual, team and, ultimately, Trust performance could be enhanced in the future, through the setting of objectives (relevant to the person’s role and experience) and the agreement of personal development plans (PDP) for all Trust staff.

The Trust performed disappointingly in the bottom 20% of mental health trusts in the 2010

Staff Survey on the key measures relating to PDR. A concerted campaign of target-setting, monitoring and profile-raising in relation to team, Division and Trust compliance in 2011 had seen appraisal rates soar to an impressive 97% which is one of the best appraisal rates for our NHS region. Audits of the process this year also reveal staff feeling supported and valued by the process, with clear data suggesting the PDR has achieved open and honest feedback on performance.

In the 2011 Staff Survey, results we have significantly improved in the following performance indicators:

• % of staff appraised with personal development plans (PDP) in last 12 months (best 20%)

• % of staff appraised in last 12 months (best 20%)

• % of staff having well structured appraisals in last 12 months (better than average)

We look forward to further progress in 2012.


Vision and Values

In October and November 2011, over 300 staff engaged in our Trust’s Value and Vision events to share and co-create the future direction of our Trust with the Executive and Divisional management teams. These staff engagement and listening events were designed as a direct outcome of both our on-going Board Development programme and a requirement to maintain effective internal stakeholder relations as highlighted within our principle risk register. The key objective of the events was to clearly communicate the Values and Vision of our services with our staff. Other objectives achieved by these events included:

• A detailed exploration of our five strategic goals

• Dialogue and contextualisation of our new values and what they mean to staff

• An introduction in Service Line Management (SLM) and Reporting (SLR)

• Engaging Staff in our Foundation Trust (FT) application

• An opportunity for staff working in a service line to share best practice

• For service lines to start to develop their own vision and future direction, drafting early objectives for inclusion in the 2012/13 business planning cycle

• A two-way listening exercise between service line staff and senior managers

The Value and Vision events were used to showcase practice across teams. This clearly demonstrated the very real way in which our organisation’s values are lived by our staff and our service users. The events have also assisted greatly in engaging and connecting frontline staff with our journey over the next five years. Feedback suggests that these events would benefit from being half annually, linking strategically with the Trust’s business planning process.

Engaging with internal stakeholders through this series of events has generated meaningful objectives for us all to take forward.

Early signs are that the Values and Vision of the Trust are better understood and more frequently reinforced. This will further be enhanced next year in performance development reviews, with clear sections on both Values and Vision enabling individuals to connect their own work with that of the Trust’s overall direction.

Service Line Management

In 2011, we introduced a Service Line Management (SLM) structure across our Trust, in order to enhance the management of specialist clinical areas as distinct operational units. Such SLM structures enable Trusts to understand their performance closer to where care is delivered and organise their services in a way which benefits patients and makes efficiencies. SLM provides a structure within which clinicians can take the lead on service development, resulting in better patient care.

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34

Over the last year we have implemented Service Line Management and agreed eight service lines:

Three within Adult Mental Health:

• Psychosis Recovery Pathway

• Non Psychotic (Common Mental Health Problems and Complex Non Psychotic problems)

• Substance Misuse;

ThreewithinChildren’sandYoung

• People’s Services

• Community Mental Health/Emotional Well Being Services

• Inpatient Mental Health Services and Children with Disabilities

• Autistic Spectrum Disorder and Psychological Consequences of Physical Ill Health

• Two within Learning Disabilities, Neuropsychiatry and Old Age Psychiatry

• Learning Disabilities

• Neuropsychiatry/Old Age Psychiatry.

Appointments to the key management posts of Clinical Leads and Service Line Managers have been made within each of the service lines, and the new management teams have started to meet.

All the service lines have developed Annual Plans for 2012/13 and will be setting key objectives during April and cascading these throughout their areas.

A Rewards and Sanctions Framework has been agreed and this will be used as a tool to drive the development of the service lines. Progress has been made to develop service line reporting mechanisms and the further development of these to provide accurate and timely information to enable management teams to makesound decisions will be a key focus of 2012/13.

4.3.3 Wellbeing Counselling

The staff support and counselling service is a high valued and core service to both NSCHT and the wider health economy.

The service strives for excellence in providing support for staff across the Trust through 1:1 counselling, team support, coaching, management supervision and critical incident stress management. The services success is in no small part due to its highly loyal and dedicated core NHS staff and professional volunteer support programme that benefits both the Trust and those who are volunteering.

Demand for the service has increased across Staffordshire in the last 12 months and the volunteer workforce has remained dedicated in the pursuit of staff well being. Despite an increase in referrals, they continue to innovate by expanding the range of therapeutic support on offer to staff and extending opening times and places, including out of hours and weekends.

This service acts as a role model within the Trust in proactively developing income streams by selling its service to neighbouring trusts and other local organisations. This includes recently securing a service level agreement with South Staffordshire PCT and renewing the SLA with the newly formed Staffordshire and Stoke on Trent NHS Partnership Trust.

This team were highly commended in our 2011 REACH staff awards


4.3.4 Training

The staff support and counselling service is a high valued and core service to both NSCHT and the wider health economy. Through our training and development activities, we have a competent skilled and appropriately trained workforce. This year we have fully reviewed our training and development policy clarifying accountabilities for all staff in relation to training and development activities. Through our Training Needs Analysis (TNA) process we have continued to create strong links between learning activities and strategic priorities and have ensured that we deliver training and development opportunities within budget. We have identified key strategic training bids with senior managers, trainers and staff and have allocated training budget to the achievement of these over the coming 12 months.

We have made significant increases in compliance towards mandatory training targets and this year achieved a 76% compliance rate overall. We have a number of action projects in place to continue this upward trend including individual work with teams and development of blended learning options with our mandatory trainers.

4.3.5 Leadership Development

This year saw the launch of our Leadership Academy, a range of leadership development programmes aimed to develop leadership capability and capacity

throughout the Trust. Three programmes ran within the academy this year. The People management programme (focusing on the transactional skills of team managers) the clinical leadership programme (focussed on the more transformational skills of clinical leaders) and the health economy leadership programme (focussing on the leadership of partnership approaches across the health economy). All of these programmes evaluated very positively and we are currently in the process of advancing these evaluation activities to more fully understand retention of learning and impact on practice.

We are currently developing the Team Leaders programme for launch in the summer of 2012 (focussing on team development, policy and practice in a modern NHS).

All of our programmes are integrated through our leadership competency framework and 360 degree tool. We have updated this tool to include a section on living the values which aligns leadership behaviours with our newly reviewed value set. We have continued to develop our use of this tool and have analysed Trust data to identify where our areas of leadership strength and development lie.

This year we have also established a mentoring and coaching pool of senior staff who have been trained in mentoring skills and are available to support aspiring and established leaders from within the organisation.


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4.4 Director of Finance and performance

The Trust’s Director of Finance and Performance is Trish Donovan. Trish has worked within the NHS for over 20 years and is a qualified accountant.

Prior to joining the Trust, Trish was Director of Finance at South Essex Partnership NHS Foundation Trust and prior to that, Director of Finance and Estates at Bedfordshire and Luton Mental Health Trust.

Trish is a member of the Chartered Institute of Management Accountants (CIMA).

She holds responsibility for all financial and performance areas of the Trust, including:

4.4.1 Performance against Key Performance Indicators (KPIs)

The Trust’s Performance & Quality Management Framework (PQMF) plays a key role in the Trust’s drive for excellence, providing a means to review and improve organisational performance and quality outcomes by linking and aligning individual, team and organisational objectives and results. It provides a means of recognising good performance and managing underperformance.

The Trust has an integrated approach to quality improvement, quality assurance and performance management which is key to the governance arrangements in operation within the Trust.

A key element of the PQMF is the balanced scorecard, which incorporates a performance dashboard. The balanced scorecard is operated across the Trust’s eight Enabling Strategies (see page 8) and is designed to measure the organisation’s performance in meeting the Strategic Objectives (SOs), Annual Objectives (AOs) and quality outcomes.

The PQMF fully integrates the balanced scorecard and the assessment process to measure compliance with the Care Quality Commission’s Essential Standards of Quality and Safety as defined by the Health & Social Care Act 2008; has an integrated risk assessment / traffic lighting process; and has direct links to the Strategic / Principal Risk Register.

Systems alone will not provide effective performance management or assurance and as such, the PQMF focuses on achievement of national and local targets through a combination of corporate processes and frontline teams.

A process that encourages the measuring and evaluation of performance to be part of everyday activity for all. It encourages integration between the measures required by different regulatory bodies and improved clinical relevance of performance measures.

For any area where performance varies significantly from plan or where monitoring identifies a worsening trend, a Recovery Plan is

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37


developed. The Recovery Plans all follow a standardised template and report:

• Target

• Currentperformance

• Reasonforunderperformance

• Actionstobetakentoaddressunderperformance (who, how, when)

• Atargetdatewhenperformanceis projected to deliver the target

4.4.2 Finance

For the 2011/12 financial year, the Trust met its statutory duty to achieve break even. Management duties in relation to cash, capital expenditure and payment of creditors were achieved.

A significant efficiency programme was delivered during the year and a revised reporting and risk assessment process was introduced to ensure all efficiency savings were risk assessed for any potential impact on service quality before they were implemented.

Financial performance is set out in Section 9.

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Working for the health & wellbeing of our local communities

5.1 Building Involvement with our Service Users and Carers

Throughout 2011/12, the Trust continued to develop links and relationships with service users, carers and their representatives.

The Foundation Trust application and Phase One consultation provided excellent opportunities to work with our service users to shape the future of our services. A review of the Trust’s stakeholder list in 2011/12 ensured that communication with a variety of statutory, voluntary, service user groups and carer representatives was as effective as possible.

The Trust enjoys close relationships with service users and carers and a very well organised North Staffs User Group. The use of patient stories, mystery shoppers and patient surveys inform the focus on continuous improvement and a discharge survey in 2011/12 showed that 93% of service users were happy with the services provided. 6.45% rated services as fair, 0.64% rated services as poor and none rated services as very poor. Matrons and managers from ward areas, resource centres and other patient settings meet regularly with service user representatives and commissioners to continually develop services in line with feedback.

A particular focus for 2011/12 has been to improve Carer Experience, outlined in CQUIN schemes. The

Trust has worked in partnership with Carers and local voluntary sector organisations to develop and implement a detailed improvement plan. This has been based on national best practice for carers and the results of a clinical team self assessment exercise, which included 36 questions around six key themes to support a good carer experience. All clinical teams across adult services completed the self assessment. Some of the key achievements to date include:

• Identification of a minimum of two carer link workers per clinical team (key role to support carers)

• Roll out of carer link worker workshops to ensure clarity of role and responsibilities to support a good carer experience

• Introduction of a carers checklist across a range of pilot areas to support the carer experience through early identification and involvement, increased supportive information being available for carers to access, increased carer support through carers assessments and local arrangements.

• Increased involvement and feedback opportunities for carers

• Introduction of a Carer’s Charter across the Trust

A review of the pilot sites will be undertaken in 2012/13, including a carer experience survey. During the next twelve months, we look forward to introducing further measures to ensure a good Carer experience across all Trust services.

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5. Working with our partners

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5.2 Patient Stories

Throughout 2011/12, the Trust has continued to collate feedback from service users and carers through the powerful tool of ‘story telling’. As a result, and to further share some of the compelling stories shared through this method, service users have suggested that that stories are compiled into a book. We will be working with service users, staff and carers to develop this during 2012/13.

In October the West Midlands Quality Review Team visited the Trust. They were very impressed with storytelling approach that had been implemented across some of the Trust’s Learning Disability Services. This involved the development of a series of pictorial stories from current and previous service users recounting their journey and experience of trust services, using techniques to capture feedback that were very meaningful and engaging for each individual. This included capturing feedback and displaying pictorially on banners. One individual chose metaphors to describe their journey and experiences whilst another individual favoured the use of songs to describe their journey and experiences. Service users and staff have since presented their work at the West Midlands Quality Review Best Practice Forum.

We look forward to continuing to develop creative and imaginative ways of capturing feedback that is both meaningful and supportive of our service users. Patient and carer stories will contribute towards the theme and agenda of Trust Board meetings.

5.3 GP associate appointments

In April 2011, the Trust welcomed two local GPs to its Board, to further strengthen the links between primary and mental healthcare. Dr Keith Tattum, from Leek, and Dr David Sheppard from Blythe Bridge joined the Trust Board as GP Associate Directors.

The aim of the roles is to provide valuable GP insight into the pathways of our patients, service users, their carers, ensuring they are as seamless as possible. Working together, and with Clinical Commissioning Groups, we are looking at ways of treating conditions in the community (where appropriate) rather than referring patients with mental health problems into hospital.

5.4 FT and Membership

In January 2012, the Trust launched a public consultation outlining its bid to achieve NHS Foundation Trust status, to allow greater autonomy and local accountability to enhance mental health, substance misuse and learning disability services.


41


Details of the Trust’s plans for the future were set out in a guide called‘HaveYourSay’.The document, introduced by the Trust’s Chair, Ken Jarrold C.B.E. and Chief Executive, Fiona Myers, outlined how the NHS Trust hopes to become an NHS Foundation Trust

Key to achieving Foundation Trust status is closer working with service users, carers, staff and local communities. Becoming an NHS Foundation Trust will help the Trust to secure the financial freedom to continue to provide the very best health care services to the people of Stoke on Trent, North Staffordshire and further afield, but to also work closely with our members as we develop future services.

NHS Foundation Trusts are still part of the NHS and have NHS inspections and standards to meet.

As a NHS Foundation Trust, North Staffordshire Combined Healthcare NHS Trust will be accountable directly to its staff, partners, local population and the people who receive its services.

As part of the application, the Trust is expected to develop a membership, headed up by a Council of Governors. The Council of Governors will be responsible for representing the interests of our local communities, service users, carers, staff and partner organisations; bringing together a forum representing their interests. The target for this membership, at the time of authorisation, is 8,500.

Foundation Trust membership provides us with the ideal opportunity to engage with our local communities to respond to local need.

Membership details:

constituency members as at 31 march 2010

members as at 31 march 2011

members as at 31 march 2012

in-year growth (from 2011 to 2012)

Public, Patient & Carer 6510 6570 6954 384

Staff 2008 2036 1895 -141

total 8518 8606 8849 243

6.1 Registration Regulations 2011/12

Since April 2010, all health and social care providers have been required by law to be registered with the CQC if they provide regulated activities. The Care Quality Commission is the independent regulator of all health and adult social care in England. They also protect the interests of people detained under the Mental Health Act and ensure that essential common standards of quality are met everywhere that care is provided. They have a wide range of enforcement powers to take action if services are deemed to be unacceptable.

The Care Quality Commission translates the Regulations defined by the Health & Social Care Act 2008 into essential standards of quality and safety. These standards place the patient at the centre of the registration system and focus on clinical outcomes and people’s experience of quality and safety rather than an administrative/management process of compiling evidence about policies and process. The Trust developed and implemented a robust self assessment process over previous years which it has fully reviewed and realigned to the new essential standards of quality and safety and support our ongoing compliance.

The Trust self assessed against the outcomes defined by the regulations and declared compliance with all the outcomes. The Trust’s application for registration was considered by the Care Quality Commission and a decision made to register without conditions (Registration Number 1-114682668) to provide a range of regulated activities from three main locations as follows:

Harplands Hospital (which includes all community based services supporting the Harplands Hospital) is registered to provide:

• Accommodation for persons who require nursing or personal care (Regulated Activity 2)

• Accommodation for persons who require treatment for substance misuse (Regulated Activity 3)

• Treatment of disease, disorder or injury (Regulated Activity 5)

• Assessment or medical treatment for persons detained under the Mental Health Act (Regulated Activity 6)

Darwin Centre is registered to provide:



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6. Governance

44

Trust HQ Bucknall Hospital (which includes all services not referred to in the two locations above - for example Child Adolescent Mental Health Services and Learning Disability Services) is registered to provide:

• Personal Care (Regulated Activity 1)

• Accommodation for persons who require nursing or personal care (Regulated Activity 2)



We understand that achieving the ‘Registration’ status is the just the beginning and it is necessary to work hard to maintain compliance with the quality standards across all of the services provided.

Internally, we continue to operate our self assessment process which has operated across the entire year to check the quality of services provided. We also use a range of external information, including feedback from staff and service users and also feedback from the CQC.

compliance Review

The CQC carried out a ‘Compliance review’ during 2011/12 to check that the Trust had made improvements in relation to assessing and monitoring the quality in service provision since its previous compliance review visit in 2010/11.

The CQC had identified areas for improvements in relation to the processes for reporting incidents and learning from both the incident reporting processes and other key processes in an integrated manner. It recommended more localised monitoring, i.e. at team level, to ensure safeguarding issues were identified and reviewed swiftly, so that there were early opportunities to reduce risks to the care and welfare of people using the service. Following the review visit, the CQC issued a formal report to the Trust. The report confirmed that improvements have been made since the November 2010 visit and that the Trust is now fully compliant with Outcome 16. The CQC found that adequate monitoring systems are in place to ensure that there are early opportunities to reduce risk to people who receive care and protect them from harm. A comprehensive action plan continues to be in place and our Quality Account includes the key priorities in this area.

6.2 estates including Sustainability Report

The North Staffordshire Estates Agency provides property management and operational estate services to North Staffordshire Combined Healthcare NHS Trust, the host organisation, North Staffs Commissioning and Support Services Organisation (referred to as the Cluster), Staffordshire and Stoke on Trent Partnership Trust, and various other healthcare type premises such as Private GP Practices, Housing Associations etc.


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The relationship with the Trust was first established twenty five years ago and has remained positive and productive throughout this period.

A significant amount of work has been undertaken during 2011/12 to develop the Estate through new builds and refurbishments of existing properties and importantly support the site rationalisation plans to move services off the Bucknall Hospital site.

In addition to this, the Team has performed routine maintenance on all essential equipment and supported the Trust in business continuity meetings throughout the year. As a result, there has been no impact on clinical service delivery through failure of estate or equipment issues.

The responsibility for contract monitoring of the PFI contract sits with the Head of Estates and formal monthly contract monitoring and a Strategic Review meeting

have identified areas for greater transparency and savings areas to be delivered with the partnering organisation.

As with all non clinical support organisations the challenge remains to the EA in attempting to improve the quality of service delivery against increasingly difficult cost savings/pressures.Patient Environment Action Team Assessment (PEAT)

patient environment Action team Assessment (peAt)

The annual PEAT audit is undertaken by a team made up of Modern Matrons, the Support Services Manager, who manage the area to be audited, Estates Operational Manager, Head of Support Services, Infection Control Nurse and representatives from North Staffs Users and LINks (Local Involvement Network) representatives who represent the general public.

The inspection team assess each site on three elements - the environment, food, privacy and dignity. Our results in 2011/12 are as follows:

Site Name 2011/12 2010/11 2011/12 2010/11 2011/12 2010/11

Bucknall Hospital Excellent Excellent Excellent Excellent Excellent Excellent

Dragon Square Community Unit Excellent Excellent Excellent Excellent Excellent Excellent

Learning Disabilities Unit Hilton Road

Good Good Excellent Excellent Good Good

The Bungalows, 1 - 6 Chebsey Close

Excellent Good Excellent Excellent Excellent Excellent

Darwin - Clydesdale Centre Excellent Excellent Excellent Excellent Excellent Excellent

Harplands Hospital Excellent Good Excellent Excellent Excellent Excellent

Environment Score Food Score Privacy & Dignity Score


46

Sustainability

The Estates Agency monitors overall use of utility consumption and provides professional advice to support the Trust’s goal of actively reducing its carbon footprint.

The Trust will continue to engage with partners across Staffordshire in developing areas of best practice, environmental training, and seminars on new technologies in order to actively explore new initiative in reducing the carbon footprint.

The Trust also has a working group in place that is focussing on the organisation moving towards becoming paperless and improving ways of working in readiness for its move to a new corporate headquarters in 2012.

Through the capital programme, investment has been made in recent years to accord with the Carbon Management Strategy and to support this goal – high efficiency boilers, VSD, low energy lighting etc. - and there have been reductions in carbon emissions as seen below:

carbon reduction target 2050

year carbon tonnes

•2008/09 CarbonEmission 1157Tonnes•2009/10 CarbonEmission 1041Tonnes•2010/11 CarbonEmission 1064Tonnes•2011/12 CarbonEmission 971Tonnes

Nonetheless, high level performance indicators for energy performance indicate that the Trust is above the median for CO2 emissions per occupied floor area (with a value of 124 compared to a median of 106) and needs to stringently attack consumption.

The chart below/overleaf shows the target profile and actual trajectory for the Trust to achieve the 80% carbon reduction by 2050.

60,000

50,000

40,000

30,000

20,000

10,000

0

- 10,000

2006 2011 2016 2021 2026 2031 2036 2041 2046

GJ

Ener

gy

CombinedHealthcare

•• ••••

•

Years

A full report is available if required.


47


6.3 Emergency Planning

Our approach to emergency planning and resilience takes account of the need to develop a whole health economy approach and compliance to requirements. We are committed to developing and maintain a prepared and resilient NHS Trust.

Resilience is about ensuring, that we are prepared for any service interruption or emergency that may occur, both internally and/or externally to the Trust, which threatens our ability to exercise our civil protection and/or ordinary functions, as required by the Civil Contingencies Act 2004.

It is Trust policy to ensure that we can continue to deliver our critical services and to support the community and our partner organisations before, during and after an emergency, in so far as reasonably practicable. By taking a proactive approach to resilience, we will be able to prioritise, deliver and support the critical healthcare systems and services that our stakeholders, patients and community rely on.

During 2011/12, we have revised and renewed our emergency major incident plans and developed a number of specific business continuity plans such as fuel shortage, loss of staff, severe weather plans etc. We have also rolled out training for key members of staff and taken part in economy wide exercises to enhance our learning and preparedness. All our policies and procedures are now available to all staff through the Trust’s intranet and newly developed sections to support staff.

6.4 Risk Management

A Quality and Risk Profile (QaRP) is a tool held and managed by the Care Quality Commission (CQC) that is used to support the CQC’s teams and providers in assessing where risks lie when monitoring compliance against the new essential standards.

The QaRP is essentially a large database of external data / evidence which is grouped under the individual registration ‘Outcome’ areas and refreshed by the CQC on a monthly basis. Each piece of data is scored and all scores are then aggregated to provide an overall monthly dashboard showing the CQC’s perception of this Trust, which it then balances against direct evidence obtained through its regular compliance reviews.

Each individual data item is scored against one of the following seven categories:

The individual data items are then aggregated to provide an overarching risk rating for each registration outcome.

Much worse than expected 7

Worse than expected 6

Tending towards worse than expected

5

Similar to expected 4

Tending towards better than expected

3

Better than expected 2

Much better than expected 1

44 | P a g e Top of the Document

In addition a summary risk perspective for the Trust is provided, together with a rolling 6-month profile of risk ratings. Data from the March 2012 QaRP is shown below:

Although the QaRP is primarily intended as a tool to support the day to day work of the CQC’s inspectors, we have incorporated it into our continuous self-assessment process as a useful cross-reference to our own internal data.

We review each QaRP to identify:

• The current risk trend direction; • Changes to the CQC’s risk rating for each registration outcome since the last report; and • Any potential areas for improvement within each of the registration outcomes i.e. data lines

scored as 5, 6 or 7 (Amber or Red)

A summary report is prepared following receipt of each QaRP for review by the Executive Team, with a more detailed report being presented to the next available Quality and Governance Committee

48



• The current risk trend direction;

• Changes to the CQC’s risk rating for each registration outcome since the last report; and

• Any potential areas for improvement within each of the registration outcomes i.e. data lines scored as 5, 6 or 7 (Amber or Red)

The Trust has in place a risk management process and monitors operational and strategic risks. This process is described overleaf.


Reducing risk of non-compliance increasing risk of non-compliance

44 | P a g e Top of the Document




• The current risk trend direction; • Changes to the CQC’s risk rating for each registration outcome since the last report; and • Any potential areas for improvement within each of the registration outcomes i.e. data lines

scored as 5, 6 or 7 (Amber or Red)

A summary report is prepared following receipt of each QaRP for review by the Executive Team, with a more detailed report being presented to the next available Quality and Governance Committee

Some data is available, but is not sufficient to calculate a risk estimate

There is no data is available to inform this outcome or group of outcomes

7

6

5

4

3

2

1

0

16

14

12

10

8

6

4

2

0

No

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ent

Dat

a

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Gre

en

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reen

Low

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ral

Hig

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al

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Am

ber

Hig

h A

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er

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Hig

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ed

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1

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11

Oct

11

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12

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11

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Insufficient Data

Low Green

High Green

Low Neural

High Neutral

Low Amber

High Amber

Low Red

High Red

Provider type: NHS Healthcare Organisation

Date registered with CQC

Number of regulated activities

Number of locations

Total no. of data items in QRP

No. of qualitative data items

No. of quantitive data items

01/04/2010

5

3

748

26

722

Summary information Latest risk estimates Risk estimates over time


49

We will continue to actively manage the Trust’s Quality and Risk Profile throughout 2012/13 to maintain the current healthy risk estimate and minimise the number of negative data lines.

6.5 Information Governance

Managing and controlling risks related to information is a key element on the risk and control framework. The Information Governance (IG) Toolkit, a tool by which the Trust assesses its compliance with current legislation, Government directives and other national guidance, is a key part of the organisation’s Assurance Framework. The Trust progressed its action plan to improve performance in the areas of Information Governance management and Information Security assurance, and successfully achieved Level 2 compliance at year end.

All Trust staff are required to complete Information Governance Training on an annual basis. Compliance is being monitored more closely by the Trust’s Organisation Development Team and it is envisaged that there will be an ongoing reduction in incidents relating to information breaches.

Data incidents

The Trust has reviewed all incidents of data loss or confidentiality breach since 1 April 2011 – 31 March 2012. There were two incident in the year from 1 April 2011 to 31 March 2012 with a severity rating of 2 and three incidents with a severity rating of 1. None of these are serious incidents which have a severity rating of 3, 4 or 5. An assessment of whether or not the incident is a serious untoward incident has been made using the guidance issued by the Department of Health as well as being considered by the Trust’s Audit Committee throughout the course of the year.

Key risks identified in 2011/12

Description of Risk Proposed action to mitigate/minimise

Quality and efficiency:

Failure to maintain quality as a result of delivering the Cost Improvement Programme (CIP)

Failure to deliver the CIP

Fortnightly CIP groupComplete quality impact assessments form part of the development of CIP schemes that are signed-off by the Medical and Nursing Directors.Reporting to the executive team and Trust Board

Quality and service changeMaintaining quality of care during the transition to new models of care

Reporting to Trust BoardIncreased frequency of monitoring visitsFeedback from internal and external monitoring processes Professional accountability across all professional groups

Relationships / commissioner expectations:External relationships with stakeholders and commissionersLeadership and internal relationships

Proactively engaging with key stakeholder groupsExecutive and non executive directors planned clinical visits.Staff Involvement and Engagement Strategy


50

6.6 equality, Diversity and Human Rights

Alongside our NHS counterparts, North Staffordshire Combined Healthcare NHS Trust aims to be a leading organisation across North Staffordshire promoting Equality and Diversity. We believe that any modern organisation has to reflect all the communities and people it serves, in both service delivery and employment, tackling all forms of discrimination. We need to remove inequality and ensure there are no barriers to health and wellbeing.

equality Analysis

In January 2012 the Trust published its first Equality Act Compliance Report. Equality analysis enables an organisation to review a new or existing service or policy from an equality and human rights perspective. It helps us to us to understand the impact of our policies and practices on the people who use our services and likewise for our staff.

Further information is available on the Trust website.

We have used the equality information to inform the development of our Equality Objectives, published in April 2012. This will ensure a direct relationship between the data and findings and the priorities set for our organisation and the planned introduction of the Equality Delivery System (EDS) the Department of Health’s equality framework.

improving the Black and minority ethnic patient experience

During 2011/12, we saw a tremendous increase in the uptake and use of interpretation services for service users and carers. This includes requests for British Sign Language (BSL) Interpreters. This is extremely positive and hopefully builds on work undertaken to promote and ensure that service users and carers are offered an interpreter even if they appear to speak English.

Past feedback collated through a Trust audit highlighted that an individual may prefer an interpreter to be present to increase confidence in discussing and disclosing information in their first language.

The Black and Minority Ethnic Patient Experience audit will be repeated in 2012.

The table below summarises the personal data related incidents in the 2011-12 financial year and includes incidents up to the date of publication of this annual report.

Category Nature of Incident Total

1 Loss of inadequately protected electronic equipment, devices, or paper documents from secured NHS premises.

0

11 Loss of inadequately protected equipment, devices or paper documents from outside secured NHS premises.

2

111 Insecure disposal of inadequately protected electronic equip-ment, devices or paper documents.

0

1V Unauthorised disclosure. 2

V Other. 1

Summary of personal Data Related incidents in 2011-12


51

6.7 complaints and compliments

complaints

The Trust continues to work to the National Complaints Regulations (The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009). These regulations stipulate principles of good complaint handling:

• Getting it right

• Being customer focused

• Being open and accountable

• Acting fairly and proportionately

• Putting things right

• Seeking continuous improvement

The Trust received 88 complaints throughout 2011/12; this represents a increase of 15% from the 75 complaints received during 2010/11.

To adhere to the regulations, the Trust is required to acknowledge all complaints no later than three working days after the day on which the complaint is received. Of the 88 complaints, the Trust acknowledged 84% within this timescale, and will continue to make improvements during the course of 2012/13.

patient Advice & liaison (pAlS) and compliments

Patients and carers are encouraged to provide feedback about their experience of services and listening to the people who use them, their loved ones and carers, is at the centre of our ethos.

PALS received a total of 273 contacts during 2011/12. People who contact this service often have several concerns or requests. Each issue is categorised and documented individually and the 349 issues raised are summarised as follows;

PALS contacts 1 April 2011 – 31 March 2012

Report number by type: YTD Report number by issue: YTD

Comments 30 Access & waiting 87

Compliments 54 Information & choice 113

Help with a problem 121 Building closer relationships 59

Cases passed to complaints dept. 19 Safe, high quality coordinated care 77

Information requests 57 Environment 13

Signposting / referrals 68

Other 0

total by type 349 totals by Area 349


52

themes

The majority of feedback to the Trust is received directly by care-teams; nevertheless, there are times when comments and compliments are made via the PALS Office.

Emerging themes identified in the last year relate to;

• Private areas for family and carers during visiting times.

• Activities available during the evening and weekend

• Communication

• Information / signposting

• Support for carers (eg information, respite etc)

The PALS Lead discusses these comments with the relevant Ward / Team Managers who respond appropriately and identify any learning points accordingly.

compliments

The Trust is receiving an increasing amount of compliments via thank you letters and cards which are now being forwarded to PALS for collation. Most contacts are very complimentary regarding staff attitude and support and this is also reflected in patient / carer stories and comments on NHS Choices and Patient Opinion which are not included within this report.

Examples of compliment are;

“The hours that all staff were required to work, the arduous tasks that they completed with serenity combined with their determination to provide the very best at all time has left me with gratitude and appreciation for the care that I received.”

Patient regarding Ward 7 (LD NOAP)“This unit and its staff should be commended; it is very obvious that the staff have a very committed and dedicated approach to its clients. This has been the most highly scored PEAT visit I have taken part in and good practice is clearly visible here.”

Volunteer regarding the Darwin Centre(CYP)

“Thank you for being a tower of strength in all sorts of ways during 2011. You are a star at the Brandon Centre… always going that extra mile. It has all done me so much good”

Patient regarding a staff member from the Brandon Centre (AMH).

“A note to say how very thankful our family are for the community psychiatric service. Our nurse is a real help; such a support to not only my mother but to the whole family. Having her visit and knowing that we can ring for help and advice when necessary (and yes we do). At last someone who ‘s got time to listen to us.”

Carer regarding Community Mental Health Services

“We always felt involved in what was going on, attending meetings etc. we felt like we were listened to. We were invited to attend a review meeting prior to her being discharged to the supportive living placement with a local private provider. The information that was provided for the new provider about meeting her needs was excellent.”

Carer regarding the Assessment & Treatment Unit (LD NOAP)


53

The PALS service is an important conduit from which the Trust can better understand patient and carer experiences. Improved reporting mechanisms are planned for 2012/13 which will mean that categories and themes will be aligned which will help us to triangulate information, identify learning outcomes more effectively resulting in improved reporting to Boards and Committees.

6.8 Freedom of information 2000 Act requests (Foi)

Every public body subject to FOI 2000 Act is required to adopt and maintain an approved Publication Scheme. A Publication Scheme is a commitment to routinely and proactively provide information to the public.

In 2011/12, the Trust responded to 98 Freedom of Information Act requests. The table below shows the types of organisations requesting information and number of requests under each category.

6.9 Serious incidents (Sis)

Since March 2011, the Trust’s approach to reporting Serious Incidents (SIs) has recognised some changes resulting in an overall increase in the number of SIs compared to previous years. In 2010/11, there were 51 incidents reported, with 11 being downgraded from SI status. In 2011/12, 82 SUIs were reported.

This increase can be accounted for by the additional reporting of abscond or failure to return from leave from inpatient care as well as improvements to the identification of appropriate incidents to be reported as an SI.

Changes to the way in which absconds and failure to return from leave reported as Serious Incidents have been recognised by Commissioners as not necessarily requiring the incident to be reported as a Serious Incident unless a serious incident has occurred as a result and it is therefore likely that a reduction may be seen in this area of reporting.

We have worked closely with commissioners to ensure that action plans in response to investigation recommendations are robust and that internal governance is in place to provide assurance to the Trust that investigations and action plans are of a level of assurance and quality to ensure lessons are learned and shared across the organisation.

type of Request number of requests

Government 5

Media 16

NHS 5

Private Business 29

Public 43

total 98


54

6.10 local counter Fraud Service

In 1999 the Secretary of State Directions were issued to trusts setting out requirements for countering fraud in the NHS.

The Local Counter Fraud Specialist provision at this Trust is provided by RSM Tenon and their officers, who report to the Trust’s Audit

Committee on all aspects of counter fraud and investigation.

A work plan was agreed by the Audit Committee and reports on progress were provided during the year. A dedicated annual report details all activities undertaken of both a proactive and reactive nature in the year 1 April 2011 to 31 March 2012.

6.11 trust Auditors

The internal auditors for the Trust are RSM Tenon and the Head of Internal Audit for the year ended 31 March 2012 was Mr Glen Palethorpe. In April 2011 the Trust’s Audit Committee received and approved the strategy for internal audit 2011/12. The plan also included flexible allocation to be used by the Committee linked to key emerging risks of the Trust.

The draft plan was discussed with the Executive Team to confirm the linkages of their work with the Trust’s objectives.

The Audit Committee has overseen the conduct of the internal audit work undertaken by RSM Tenon in 2011/12. During the year much emphasis has been placed on overseeing Internal Audit Recommendations and considering reports in relation to audits completed to date, assurance levels and progress in the implementation of audit recommendations.

The Trust continues to take audit recommendations seriously. Work will continue during 2012/13 to maintain progress in this regard and ensure that target dates for completion of audits are achieved.

The Audit Committee will focus its attention on high level actions and exception reporting.

The Trust’s external auditors are appointed by the Audit Commission. The external auditor for 2011/12 was KPMG. Their Appointed Auditor was Mr Andrew Bostock.

The Trust’s Audit Committee reviews the work and findings of the External Auditor and considers the implications and management’s responses to their work. The committee considered and approved the external audit plan and fees for 2011/12.

During the year the committee has received regular external audit progress reports, which have highlighted work being carried out and planned activity.

Work in relation to the Quality Account has been undertaken and the fee of £12,500 has been mandated by the Audit Commission. A charge of £5,000 was made for data quality work undertaken in this regard.

Each year the External Auditor provides an audit memorandum setting out the key findings from all of the external audit work


55


performed in the previous financial year. It is a requirement of the Code of Audit Practice, issued by the Audit Commission, that the Audit Committee receive a summary of the work of external audit at the time when they are considering the financial statements.

The External Auditor is also required to produce an annual audit letter each year. The purpose of the audit letter is to advise the directors of the key issues arising from their work.

In May 2011 the Audit Committee received the KPMG ISA 260 report which summarised value for money

and accounts. The committee noted the headlines and reviews undertaken of the Trust’s CIP process, board and finance papers. Auditors confirmed that the information they had received on the accounts had been completed on time and were of a good standard.

The Trust is obliged to disclose the cost of work performed by the external auditor in the year to 31 March 2012. The costs were as follows:

Audit Services Statutory audit and services carried out in relation to the statutory audit.

Charity audit

£98,040 (ex vat)

£6,375 (ex vat)

Further Assurance Services Services unrelated to the statutory audit where the Trust has discretion whether or not to appoint an auditor.

0

Other Services Any other services provided. 0

All directors can confirm that, as far as they are aware, there is no relevant audit information of which the NHS body’s auditors are unaware. They have taken all the steps that 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 body’s auditors are aware of that information.

• SirPhilipHuntersteppeddownasChairmaninSeptember2011

• MrIanAshboltsteppeddownasNonExecutiveDirectorinSeptember2011

• DrChristineKingsteppeddownasNonExecutiveDirectorinSeptember2011

57


7. Our Trust Board

7.1 Details of our Directors

Name Position Appointed

Ms Fiona Myers Chief Executive August 2008

Mrs Patricia (Trish) Donovan Executive Director of Finance March 2011

Dr. Olubukola (Buki) Adeyemo Executive Medical Director January 2012

Mr David Pearson MBE Executive Director of Nursing and Al-lied Health Professionals

October 2001

Mr Steve Gregory Executive Director of Nursing and Al-lied Healthcare Professionals

February 2012

Executive Directors as at March 31, 2012*

Director in attendance at board (non-voting)


Mrs Caroline Donovan Director of Leadership and Workforce June 2010 (Substantive) June 2009 (Interim)

*There were a number of changes to the executive membership of the Board in 2011/12, namely:

• JulianAucklandLewissteppeddownasChiefOperatingOfficerinJanuary2012

• DrMikeJorshsteppeddownasMedicalDirectorinDecember2011


Ken Jarrold CBE Chairman Appointed December 2011 – 4 year term

Tony Gadsby Non Executive Director Appointed November 2009 - 4 year term

Jennifer Perks Non Executive Director Re-appointed December 2010 - 4 year term

Fred Worth Non Executive Director Re-appointed November 2009 – 4 year term

Judith Griffin Non Executive Director February 2012 – 4 year term

Nicholas Hoare Non Executive Director February 2012 – 4 year term

Non Executive Directors as at March 31, 2012**

Dr David Sheppard Associate GP Appointed April 2011

Dr Keith Tattum Associate GP Appointed April 2011

Associate Directors

**There were a number of changes to the Non-executive membership of the Board in 2011/12, namely:

58

In November 2007, the Trust Board requested that a formal register of acceptance of the Code of Conduct and Code of Accountability in the NHS is established. All Directors have provided a signed declaration of their acceptance of the Code of Conduct and Code of Accountability in the NHS to the Trust Secretary:

The Code of Conduct and Code of Accountability in the NHS can be viewed on the Department of Health website at:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4116281

7.2 Details of our Directors’ declared private interests

As at 31 March 2012

NAME OF DIRECTOR INTEREST DECLARED

K Jarrold, Chairman •NHSRetirementFellowship,Patron•CountyDurhamEconomicPartnership,Chair(untilJuly2012)•TheDeardenPartnershipLLP,Partner•UniversityofDurham,HonoraryProfessor

F Worth, Non Executive Director •TheRoyalMencapSocietyLtd,Trustee•TheSocialInvestmentBusiness(TSIB)Ltd,Director•AdventureCapitalFundLtd,Trustee•3SC,SIBBoardRepresentative

J Griffin, Non Executive Director •JudithGriffinLimited(Consultancy),Director

N Hoare, Non Executive Director •WatbridgeInterimLimited,Director

J Perks, Non Executive Director •EccleshallDayCareCentreAction,Chairman

T Gadsby, Non Executive Director •LionsClubInternational(LCI),ChairmanofGovernors,British...Isles & Ireland•LCIMD105WelfareTrust,Trustee•LCIMD105SightConservationTrust,Trustee•LCIMD105YouthTrust,Trustee

F Myers, Chief Executive •Nointerestsdeclared

Dr B Adeyemo, Executive Medical Director

•Nointerestsdeclared

D Pearson, Executive Director of Nursing and AHPs

•ParishCouncil,Councillor

T Donovan, Executive Director of Finance


S Gregory, Executive Director of Nursing & AHPs


REGISTER OF ACCEPTANCE OF THE CODE OF CONDUCT AND CODE OF ACCOUNTABILITYINTHENHS


59


This report provides information about the remuneration of the Trust’s Directors and those who influence the decisions of the Trust as a whole.

The Chief Executive has confirmed that for North Staffordshire Combined Healthcare NHS Trust this report will include the Executive Directors and the Director of Leadership and Workforce (collectively referred to as very senior managers) and the Non Executive Directors, including the Chairman.

The Remuneration and Terms of Service Committee has responsibility to determine the remuneration of a wider group of staff. However, as their duties do not meet the definition provided above, details about their remuneration, and that of other employees, are not included in this report.

Duties and Membership of the Remuneration and Terms of Service Committee

The Trust Board has established a committee of the Board which is known as the Remuneration and Terms of Service Committee.

The current terms of reference of the Remuneration and Terms of Service Committee were revised and approved by the Trust Board in February 2012. The Terms of Reference will be reviewed at least annually and the next review must take place before 31 December 2012.

The purpose of the Committee is to determine appropriate remuneration and terms of service for the Chief Executive, Executive Directors and other senior management employed on Trust terms and conditions, including:

• all aspects of salary (including any performance related elements / bonuses);

• additional non pay benefits, including pensions and cars;

• contracts of employment;

• arrangements for termination of employment and other contractual terms; and

• severance packages (severance packages must be calculated using standard guidelines any proposal to make payments outside of the current guidelines must be subject to the approval of the Treasury).

8. Remuneration Report

60

The membership of the Committee shall be the Chair of the Trust Board and all the non-executive directors appointed by the Trust Board.

The Trust Chair shall Chair the Committee. In the absence of the Chair one of the other non-executive directors will be elected by those present to Chair the meeting.

The Committee meets at least twice per year although meetings are called more frequently when vacancies arise. Meetings can be called at the discretion of the Chair. Only the Chair and relevant members are entitled to be present at a meeting of the Committee, but others may attend by invitation of the Committee.

The Committee is supported by the Trust Secretary and the Chief Executive and Director of Leadership & Workforce attend meetings as required.

The Director of Leadership & Workforce attends to advise on:

• trends in pay and benefits;

• alignment of reward policies and trust objectives;

• the relevance of surveys and changes in reward practice; and

• the application and impact of external regulation on appointment, compensation, benefit and termination practice (e.g. Nolan, Strategic Health Authority instruction).

Those in attendance are required to withdraw from meetings for the consideration of business in which they are personally interested.


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61


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62

Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation’s workforce.

The mid-point of the banded remuneration of the highest-paid director in North Staffordshire Combined Healthcare NHS Trust in the financial year 2011-12 was £122,308. This was 4.4 times the median remuneration of the workforce, which was £27,625.

In 2011-12, 4 employees received remuneration in excess of the highest-paid director. Remuneration ranged from £138,390 to £190,401

Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind as well as severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions.


63

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64

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9.1 introduction to Financial Statements 2011/12

We are pleased to report that, as in previous years, the Trust achieved its key financial objectives for the year ended 31st March 2012, as illustrated in this report.

As an NHS trust, we have a statutory ‘breakeven’ duty, which requires that we ensure our income is sufficient to meet our expenditure, taking one year with another.

In 2011/12, we achieved an operational surplus of £0.9m, after allowing for technical items in relation to fixed asset impairments and the accounting treatment of the Trusts PFI (Private Financing Initiative) Scheme (retained total deficit £7.8m).

cost improvement programme (cip)

In common with the rest of the NHS, 2011/12 saw the Trust operating in an increasingly

pressured financial environment. Pressures included national and local cost improvement requirements, cost inflation, increased pay costs due to staff progression within salary scales and a need to invest in information system and associated infrastructure enhancements.

In order address these financial constraints and still meet clinical service specifications and maintain quality, all divisions and corporate areas identified a five year CIP programme as part of the development of the Trust’s Integrated Business Plan with a series of the schemes commencing in 2011/12.

Delivery of the efficiency agenda was a key risk to achievement of the overall financial plan for 2011/12 and whilst some slippage was encountered against the recurrent plans, sufficient non recurring savings were substituted such that the overall efficiency requirement was met.

65


9. Summary Financial Statements for the period 1st April, 2011 to the 31st March, 2012

2007/08 2008/09 2009/10 2010/11 2011/12

£000s £000s £000s £000s £000s

Turnover 87,021 90,910 90,599 86,321 83,063

Retained Operational Surplus fortheYear

214 256 449 698 891

66

income and contracts

The reported financial performance of the Trust shows that the organisation has managed to achieve surpluses consistently during an era of relatively static overall income. The Trust has, however, experienced a number of individual strategic shifts in income streams that have resulted in significant changes to its portfolio of services.

These included the changes from the traditional income profile, where a very high proportion of clinical income was received from local PCTs, towards a more mixed portfolio of income streams. Significant income contracts have moved from PCT commissioners to the Local Authority, increasing specialist service income has been received from the West Midlands Specialist Commissioner and there has also been a rise in non-clinical income.

During 2011/12, the Trust saw the third year of operation of local partnership agreements with both Local Authorities for social care services for adults with mental health needs, and Improving Access to Psychological Therapies (IAPT) service that was secured at the end of 2008-09.

External Financing Limit (EFL) and Capital Resource Limits (CRL)

For 2011/12, the Trust was given an External Financing Limit (effectively a cash limit) to work within. It is permissible to undershoot the limit, but not to exceed it. In 2011/12 the Trust under-utilised this limit by £0.5m.

The Trust is also given a Capital Resource Limit. In 2011/12, the Trust had a reduced capital programme whilst future service plans and the Estate strategy were under development. Accordingly it under-utilised the Capital Resource Limit by £0.9m.

It is permissible to undershoot the EFL and/or CRL but not to overshoot. The Trust managed within the set limits and, therefore, delivered its management responsibility.

Better Payment Practice Code Measure of Compliance

The Trust has a number of targets in relation to prompt payment of creditors, namely

(i) To pay non-NHS trade creditors in accordance with the CBI (Confederation of British Industries) prompt payment code and Government accounting rules. The target is to pay creditors within 30 days of receipt of goods or a valid invoice (whichever is the later) unless other payment terms have been agreed with the supplier. We paid 97% (based on value) of invoices within the target.

(ii) To monitor payments to other NHS organisations against a similar target of payment with 30 days. We paid 90% (based on value) of invoices within the target.(iii) to disclose any charges made by suppliers under the Late Payment of Commercial Debts (Interest) ACT 1998. The Trust did not incur any such charges in 2011/12.


67


Capital Cost Absorption Rate

The Trust is required to pay dividends on public capital at a rate of 3.5%, calculated on average relevant net balance sheet assets. This amounted to £0.919m for 2011/12 based on assets averaging £26.3m.

Planning and ForecastsThe Trust has completed a planning process and produced our draft five-year Integrated Business Plan (IBP) and Long Term Financial Model (LTFM), which were approved by the Trust Board and submitted to the Strategic Health Authority in March 2011. This serves as both the Trust’s key direction of travel and business plan and will facilitate an application to become a Foundation Trust.

The draft IBP and LTFM have been constructed to take account of anticipated future pressures facing the NHS nationally and locally. A small number of service

developments including increased delivery of services in community settings, liaison services and seeking ways to work differently across the health economy are being explored. These are being considered alongside the ongoing requirement to deliver efficiencies and to redesign services to improve quality and patient satisfaction, thus ensuring services are fit for purpose going into the future.

The Trust, therefore, has a challenging five year plan generating modest annual financial surpluses, for future re-investment. The continuation of sound financial stewardship remains vital whilst we implement this plan.

9.2 Statement of Comprehensive Income for the Year Ended 31 March 2012

31 march 2012 31-mar-11

£000 £000

Revenue from patient care activities 70,208 73,907

other operating revenue 12,855 13,186

operating expenses -89,161 -84,769

Operating surplus -6,098 2,324

Investment revenue 697 479

Gains on disposal of Non Current Assets held for sale 58 0

Finance costs -1,514 -1,541

Deficit for the financial year -6,857 1,262

Public dividend capital dividends payable -919 -957

Retained surplus for the year -7,776 305

Reconciliation to operational Surplus

The following items are included in the retained surplus above but are considered exceptional and do not count towards the measurement of the Trusts Operational Position

Asset Impairments Reversal 8,041

Increased Financial Impact in respect of PFI schemes 626

Revised operational surplus 891

other comprehensive income

Impairments and reversals 0 -2

Gains on revaluations 839 626

Receipt of donated/government granted assets 0 0

Net loss on other reserves - LGPS - defined benefit pension scheme

-1,169 6,195

Net gains/(losses) on available for sale financial assets 0 0

Total comprehensive income for the year -8,106 7,124

68


9.3 Statement of Financial Position as at 31 March 2012 31 march 2012 31-mar-11

£000 £000

non-current assets

Property, plant and equipment 39,568 47,063

Intangible assets 177 191

Trade and Other Receivables 478 965

total non-current assets 40,223 48,219

current assets

Inventories 87 104

Trade and other receivables 3,757 3,672

Cash and cash equivalents 5,257 4,597

Non-current assets held for sale 0 312

total current assets 9,101 8,685

total assets 49,324 56,904

Current liabilities

Trade and other payables -5,831 -5,170

Borrowings -352 -287

Other financial liabilities 0 0

Provisions -1,170 -1,330

net current assets 1,748 1,898

total assets less current liabilities 41,971 50,117

non-current liabilities

Borrowings -14,098 -14,450

Provisions -691 -264

Trade and Other Payables -112 -227

Other liabilities 0 0

total assets employed 27,070 35,176

Financed by taxpayers’ equity:

Public dividend capital 7,998 7,998

Retained earnings 13 5,510

Revaluation reserve 18,581 20,952

Other reserves 478 716

total taxpayers’ equity 27,070 35,176


69

9.4 Statement of cash Flows for the year ended 31 march 2012

2011/12 2010/11

£000 £000

cash flows from operating activities

Operating deficit -6,098 2,324

Depreciation and amortisation 1,658 1,765

Impairments and reversals 8,041 -184

Transfer from donated asset reserve 0 0

Transfer from government grant reserve 0 0

Interest paid -1,509 -1,536

Dividends paid -1,050 -745

Decrease in inventories 17 42

Decrease in trade and other receivables -85 932

Increase in trade and other payables 303 631

Increase in other liabilities 0 716

Increase decrease in provisions 262 -1,050

net cash inflow from operating activities 1,539 2,895

cash flows from investing activities

Interest received 15 15

Payments for property, plant and equipment -982 -1,133

Proceeds from disposal of plant, property and equipment 414 0

Payments for intangible assets -39 -179

Outflow from investing activities -592 -1,297

net cash inflow before financing 947 1,598

Cash flows from financing activities

Public dividend capital repaid 0 0

Capital element of finance leases and PFI -287 -254

net cash inflow/(outflow) from financing -287 -254

net increase in cash and cash equivalents 660 1,344

70


9.5 notes to the Summary Financial Statements

Better Payment Practice Code - Measure of compliance

The Better Payment Practice code requires the 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 Trust has not yet signed up to the Prompt Payment Code imitative developed by the Department for Business, Enterprise & Regulatory Reform (BERR) and the Institute of Credit Management (ICM)

2011/12 2011/12 2010/11 2010/11

Number £000s Number £000s

Total Non-NHS trade invoices paid in the year

12,730 18,503 14,254 18,565

Total Non NHS trade invoices paid within target

11,669 17,875 12,863 17,708

Percentage of Non-NHS trade invoices paid within target

92% 97% 90% 95%

Total NHS trade invoices paid in the year 605 6,198 601 7,146

Total NHS trade invoices paid within target

562 5,586 581 6,907

Percentage of NHS trade invoices paid within target

93% 90% 97% 97%


71

72

9.6 Statement of Accounting officer’s Responsibilities

Under the National Health Service Act 2006, the Secretary of State has directed the Chief Executive of North Staffordshire Combined Healthcare NHS 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 North Staffordshire Combined Healthcare NHS Trust and of income and expenditure, changes in taxpayers’ equity and cash flows for the financial year.

In preparing the accounts, the Accounting Officer is required to comply with the requirements of the Government Financial Reporting Manual and in particular to:

• observe the Accounts Direction issued by the Secretary of State, 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 Government Financial Reporting Manual have been followed, and disclose and explain any material departures in the accounts/financial statements; and

• prepare the accounts/financial statements on a going concern basis.

The Secretary of State has appointed the Chief Executive as Accounting Officer of North Staffordshire Combined Healthcare NHS Trust. The responsibilities of an Accounting Officer, including responsibility for the propriety and regularity of the public finances for which the Accounting Officer is answerable, for keeping proper records and for safeguarding the Trust’s assets, are set out in Managing Public Money published by the HM Treasury.

Fiona MyersChief Executive7th June 2012


73

9.7 Statement of Directors’ Responsibilities in Respect of the Accounts

The Directors are required under the National Health Service Act 2006 to prepare accounts for each financial year. The Secretary of State, with the approval of the Treasury, directs that these accounts give a true and fair view of the state of affairs of the Trust and of the income and expenditure, recognised gains and losses and cash flows for the year. In preparing those accounts, Directors are required to:

• apply on a consistent basis accounting policies laid down by the Secretary of State with the approval of the Treasury;

• make judgements and estimates which are reasonable and prudent;

• state whether applicable accounting standards have been followed, subject to any material departures disclosed and explained in the accounts.

The Directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the Trust and to enable them to ensure that the accounts comply with the requirements outlined in the above mentioned direction of the Secretary of State. They are also responsible for safeguarding the assets of the Trust and hence for taking steps for the prevention and detection of fraud and other irregularities.

The Directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the accounts.

By order of the Board

7th June 2012 Fiona Myers, Chief Executive

7th June 2012 Trish Donovan, Director of Finance


74

9.8 independent Auditor’s Report to the Board of Directors


75


1. Scope of responsibility

The Board is accountable for internal control. As Accountable Officer and Chief Executive of this Board, I have responsibility for maintaining a sound system of internal control that supports the achievement of the organisation’s policies, aims and objectives. I also have responsibility for safeguarding the public funds and the organisation’s assets for which I am personally responsible as set out in the Accountable Officer Memorandum.

The performance of the Trust is monitored by the NHS West Midlands and East Cluster. The Trust’s performance is assessed by the submission of data and by meetings between Strategic Health Authority and Trust staff.

The Trust has a range of formal and informal mechanisms in place to facilitate effective working with key partners. These include participation in partnership boards which bring together health, social care, independent and voluntary sector organisations in the City of Stoke on Trent and the County of Staffordshire.

The Trust has Health and Social Care Act (Section 75) 2006 partnership agreements with Stoke on Trent

City Council (since April 2008) and Staffordshire County Council (since May 2009) for the provision of adult community mental health services. There are systems in place to ensure effective working with these partner organisations, including formal meetings between senior officers from the partner organisations to oversee the partnership agreements.

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 organisation’s policies, aims and objectives;

• evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.

77


10. NHS Governance Statements (formerly Statement

of Internal Control)

78

the system of internal control has been in place in north Staffordshire combined Healthcare nHS trust for the year ended 31 march 2012 and up to the date of approval of the annual report and accounts.

The Annual Governance Statement has been prepared following the guidelines published by the Department of Health on the 28 March 2012 which sets out how and where NHS organisations are required to make disclosures or qualifications within their Statement.

3. the trust’s Governance Framework

We have re-examined our governance arrangements to ensure they are effective and we have assessed the role of the Board and our committee structure along with the flow of information to the committees and the Board.

• There are annual cycles of business for the Board and its committees;

• Attendance is monitored and there is regular attendance at Board and committee meetings;

• There is enhanced performance management reporting with a balanced scorecard aligned against the strategic and annual objectives and the on-going development of the management information pack;

• There is an effective Assurance Framework, which is the system used by the Board to ensure that all principal risks are effectively managed and that the effectiveness of those controls has been assured.

• All committees are chaired by a Non Executive Director and committee terms of reference are reviewed and agreed annually. The last review took place in January 2012. The Trust’s auditors have confirmed our terms of reference are fit for purpose and there are no gaps in business or unnecessary duplication. We will keep this under regular review during the course of 2012/13.

The board has revised and agreed its structure to support the delivery of business, as outlined below:

trust Board

Audit committee Quality &governance committee

Charitable fundsManagement &

security committee

Remunerationcommittee

Finance & activitycommittee


79


3.1 the Audit committee

The Audit Committee monitors and reviews the establishment and maintenance of an effective system of integrated governance, risk management and internal control across both clinical and non clinical activities, which support the achievement of the organisation’s objectives. This committee met six times during the course of the year.

3.2 the Finance and Activity committee

The Finance & Activity Committee is responsible for reviewing and scrutinising all activity, financial and treasury management, and takes action where necessary, making recommendations to the Board. This committee also acts as the Trust’s risk management committee and oversees the management of risk for the Trust. This committee meets monthly.

3.3 the Quality and Governance committee

The Quality & Governance Committee advises the Finance & Activity of any operational and clinical risks that they consider pose a threat to the delivery of services. It manages and monitors performance at a strategic level covering the issues relating to efficiency, workforce, service user experience, clinical quality, access targets and safety. This committee has met at least monthly/every six weeks during the course of the year

3.4 the charitable Funds management and Scrutiny committee

This committee ensures that the charitable funds are managed in line with agreed policies on investment, disbursement and fund

raising. This committee met twice during the year.

3.5 Remuneration and terms of Service committee

This committee is responsible for determining the remuneration and condition of service of Executive Directors, ensuring that these people properly support objectives of the Trust, represent value for money, comply with statutory and NHS/DH requirements. This committee met four times during the year.

3.6 effectiveness Review

During the year our Board membership has been refreshed. The Board now has a wide range of experience and skills to provide effective leadership. Two GP Associate Board members were also appointed, which has strengthened the Board from a primary care perspective.

Our continuous cycle of board development activities acts as an organisational catalyst. A core component of the programme is to ensure that all board members have a very clear focus and understanding of their role in order that they will lead the organisation to deliver the highest quality of safe services for our community, within resources available.

A board development workshop took place during the year of which the focus was the new Board Governance Assurance Framework (BGAF) for aspirant Foundation Trusts. The Board Governance Memorandum has been completed and the Board is committed to considering any recommendations that are made as result of the external validation.

80

In reviewing its effectiveness during the year, the Board has also looked at improving the flow of information to the Board, particularly the presentation of risk and financial information. Most significantly the Board commissioned an external review of the quality and governance arrangements against Monitor’s Quality Governance Framework. The Quality and Governance Committee introduced new quality governance reporting arrangements which ensures more robust reporting of activities and progress resulting in a more meaningful review by the Board.

As part of this review, the Board now receives timely updates on the key issues arising from each committee meeting from the relevant Chair. This is also supported by a written summary of the key items discussed by the Committee and decisions made. Board members also have access to all papers and minutes of those meetings, as required.

An example of highlights, notably by the Audit Committee, relate to progress against audit recommendations, any significant gaps in key controls or assurances, information governance breaches and remedial action.

3.7 Quality Account 2011/12

By June 2012 the Trust will have developed and published its Quality Account. In order for the Board to assure itself that the Quality Account is managed in an effective and timely way and that the Quality Account is accurate, a project plan was implemented and discussed

at committee meetings and at the Trust Board. This plan sets out the review and planning framework, including engagement and review by key stakeholders in developing the document, incorporating feedback and their final validation.

3.8 Board Assurance Framework

We have a fully documented Board Assurance Framework (BAF) and produce assurance framework reports. The Audit Committee receives regular reports and provides assurance and makes recommendations to the Board. The principal objectives of the Trust form the basis of the BAF. The Assurance Framework maps registration outcomes, principal risks, key controls, gaps in control, assurances and gaps in each against one of the principal objectives.

The Assurance Framework operates as follows:

• The Board set out what the Trust is trying to achieve (the Trust’s strategic and annual objectives);

• The Board consider the risks that threaten the delivery of its plans (the principal risks);

• The Board decide what systems and processes are required to manage the risks (the controls);

• The Board decide what information it needs to know and that the controls are working effectively (the assurances);

• The Board delegate responsibility for receiving some assurance to its committees;

• The Board receives feedback about the adequacy of its control arrangements and takes action as required.


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This process provides a framework of assurance about the system of integrated governance, risk management, and internal control, across the whole of our activities (both clinical and non-clinical), that supports the achievement of the organisation’s objectives.

As such, the Trust Board and its committees take an active role in risk management and ensure that there are effective risk management processes to support the achievement of the Trust’s policies, aims and objectives. The Trust has had a risk management strategy in place for many years. The Risk Management Strategy and the Risk Management Policy are reviewed and refreshed on an annual basis and are reviewed by the appropriate committees and endorsed by the Board. Together they create a framework for the consideration of risk at all levels within the organisation and mandate the maintenance of a register of all risks. The risk register is a dynamic tool which is updated as circumstances change and is subdivided into two parts; principal risks and operational risks. The Risk Register sets out how these different types of risks are identified measured and monitored.

The aims of the Risk Management Strategy and Risk Management Policy are to:

• maintain the highest possible standards of service delivery where the numbers of serious errors are few relative to the volume and complexity of activity undertaken;

• support the achievement of the Trust’s principal objectives in an efficient and effective manner, delivering value for money; and

• Ensure that risk management arrangements are continually strengthened and combined with robust control and reporting arrangements to create an effective system of integrated governance.

The Risk Management Strategy and Risk Management Policy set out the Trust’s approach to the management of risk. They define the way in which risks are identified, measured and managed and the management of situations where control failure leads to the realisation of risk. They clearly define the roles and responsibilities of key managers and committees and set out the specific responsibilities of the Directors for the effective management of risk. The Risk Management Strategy and Risk Management Policy set out the organisation’s plans for improving its capacity to identify measure and manage risk and for ensuring that the Trust continues to be a safe and reliable organisation in the conduct of the services it delivers.

The current Risk Management Strategy was approved by the Trust Board in March 2010 and is in place from 2010/11 to 2015/16. The Risk Management Strategy was reviewed in year during June 2011 and is due to be reviewed again by the Board in June 2012.

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Work has progressed during 2011/12 and there have been later iterations of the Integrated Business Plan (IBP). Work has also progressed with regard to the development and implementation of the enabling strategies that underpin the IBP. One of the enabling strategies is the Governance Strategy. The Governance Strategy is supported by the Performance and Quality Management Framework (PQMF); the Risk Management Strategy; the Assurance Framework and the Communications and Membership Strategy. A Governor Engagement Strategy is also being developed so this is in place post authorisation as a Foundation Trust.

The key process objectives set by the Trust Board for the development of risk management are:

3.8.1 to further develop integrated governance arrangements.

An Integrated Quality Report has been introduced during the year which brings together all intelligence to enable the Board to clearly identify emerging themes and trends and learning outcomes. Commissioners have welcomed this report.

During the year an audit of the Assurance Framework was undertaken as part of the internal audit periodic plan for 2011/12. The review sought to validate the design and application of the Assurance Framework in relation to ongoing development and maintenance. The audit gave a positive opinion and highlighted many examples of strong practice.

Of note is that the components of the Framework have all been explicitly mapped out against each other so that an assurance can be mapped back to a Corporate Objective with ease. In addition all assurances are ranked in order to meaningfully assess the reliability, accuracy and usefulness of each assurance in relation to objective. During the year, Assurance Framework reports (which are process focussed) have been strengthened to draw out more explicitly the gaps in control and assurance identified in the Assurance Framework and agreed actions to address them. Revising the report in this way has helped to identify issues more easily and bridge to other more detailed performance reports.

An audit of the Assurances on the Achievement of the Trust’s Principal Objectives was undertaken as part of the approved internal audit periodic plan for 2011/12. The review sought to validate that individual sources of assurance were actually in existence and that they were appropriate for the objectives against which they had been listed. Testing was performed against six of the Trust’s principal objectives and consideration was given to over 100 assurances as identified on the Assurance Register. The audit gave a positive opinion and concluded that the assurances recorded within the Assurance Register of the Assurance Framework were in existence and up to date. No recommendations were made to improve our processes in this area; however we will keep our processes under review.


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During the year an audit of the Care Quality Commission – Reporting Framework supporting the monitoring of the CQC registration was undertaken as part of the approved internal audit periodic plan for 2011/12. The audit gave positive assurance and concluded that the Trust can take substantial assurance that the controls upon which the organisation relies to manage this area, are suitably designed, consistently applied and effective. Many examples of robust practice were highlighted, of note is that evidence is being gathered through the Trust’s Compliance Assessment Document (CAD) which has been developed as part of the Trust’s self assessment methodology and ensures that all Lead Officers take a consistent approach to evidence collation.

3.8.2 To further raise awareness.

The Trust has reviewed again the effectiveness of risk management training and continued to ensure that there is appropriate advice and training available for the Trust Board and key managers.

3.8.3 To improve performance in risk management year on year.

During 2011/12 significant progress continues to be made in the development of the Trust’s understanding of strategic risk and the development of mitigations to respond to those risks.

An integral part to the development of the Divisional Level Business Plans and the Trust’s IBP has been the development of a clear listing and analysis of all

strategic risks including the gross, residual and projected risk scores. Each residual risk is reviewed regularly by the Executive Team and Operational Management Group and actions taken during the course of the year to mitigate those risks identified.

The Trust was subject to re-assessment against Level one of the NHS Litigation Authority Risk Management Standards in January 2011. The Trust successfully retained level one accreditation, which demonstrates that the Trust has documented effective risk management systems and processes in place. A strategic plan is in place to progress to NHSLA Level 2 accreditation, including self assessment and detailed action plans.

3.8.4 Utilise effective Information Technology

Work is ongoing to look at alternative options for developing or procuring an electronic risk assessment system / risk register which meets the Trust’s needs.

3.8.5 Preparation for Foundation Trust Status

In further preparation for Foundation Trust Status there have been ongoing developments in year to the risk management processes to ensure that the Trust is in a position to respond to the requirements of Monitor’s Compliance Framework.

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4. Risk Assessment

The Board defines its objectives on an annual basis in line with the strategic planning cycle and identifies the risks which could pose a threat to those objectives. Once identified, the risks form the principal risk register, are formally reassessed by the executive team on a quarterly basis, and monthly by exception, and risk treatment plans are developed to ensure that the risks are mitigated. The executive team is informed by other key processes and intelligence derived through other sources to ensure that this process is dynamic and effective. The outcome of this process is reported to the Board.

The organisation seeks to involve public stakeholders in managing risks which impact on them. The Trust also invites a range of organisations including local Overview and Scrutiny Committees, to review the performance and comment on the performance of the Trust, particularly in regard to its ongoing compliance with Registration under the Health and Social Care Act 2008.

Our operational risks are identified at local, divisional and corporate level. The identification process takes many forms and involves both a pro-active approach and one which reviews issues retrospectively. A great deal of emphasis is placed on predicting where incidents could occur and taking steps to stop them before they do. Our risk register is populated as a minimum by operational risks which fall into the categories of moderate, significant or high risks and risk treatment plans are in place for all risks in

these categories. The Finance and Activity Committee ensures through regular review that risk treatment plans are in place to respond to all operational risks on the risk register and that those plans are implemented.

We have assessed our strategic, operational, financial, information management and technology, and human resource risks based upon our divisional and Trust-wide SWOTs and the market assessment. We have also increased our focus on reviewing our risk profile and considering the risk to the safety and quality of services by assessing the potential impact on quality resultant to the financial pressures and required service changes.

As at 31 March 2012, the Trust’s residual high and significant principal risks are:

• Failure to develop robust financial plans / performance

• Failure to develop robust cost improvement plans

• Failure to implement the cost improvement plans

• Failure to develop relationships with internal stakeholders


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While we have a robust monitoring and quality assessment process in place for all CIP schemes, we also recognise the significant challenge of the financial agenda and the criticality of maintaining safe, high quality services whilst making recurrent efficiencies.

Our IBP includes consideration of potential downside scenarios assessed for their impact on income and expenditure and on cash. We have identified potential mitigations and continue to review this as a key element in preparing our FT application.

The risk in terms of development of relationship reflects the importance of communication across the variety of internal and external stakeholders including our staff, service users and carers, new NHS commissioning organisations and other partners. We have further developed our communications, engagement and membership strategies in recognition of the importance of this area.

A Quality and Risk Profile is a tool held by the Care Quality Commission and is used to support the CQC’s teams and providers in assessing where risks lie when monitoring compliance against the new essential standards. The individual data items, which are aggregated on a monthly basis to provide an overarching RAG rated dial per outcome area and per section is closely monitored by the Executive Team and committees of the Board, the learning from which has helped to inform the risk management process.

During the year a review was undertaken of how risk is managed and presented to the Board. The Executive Team agreed a number of reporting and process changes at operational level, including updates to operational risk registers, calculation of risk appetite and a review of the electronic risk register. In addition the Principal Risk Register is now presented to the Board using two new charts, namely:

A principal risk profile – indicating the spread of risk, and

A quarterly risk appetite and controllability matrix – indicating the current assessment of principal risk and the trust’s appetite for management of these items.

5. the risk and control framework

As identified, there is a clear and well defined approach to the identification of risks. The identification process takes many forms and involves both a pro-active approach and one which reviews issues retrospectively.

The organisation’s risk analysis system uses descriptive scales to determine the magnitude of the potential consequences of an identified risk and the likelihood that those consequences would occur. Consideration of the controls in place for the risk and the effectiveness of those controls also form part of the assessment. Using this method enables the production of a list of prioritised risks with an indication of the action that is required.

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A risk review group regularly reviews the operational risk register and advises the Finance and Activity committee, who act as the Trust’s Risk Management Committee, of any risk with a focus on those which threaten the delivery of the Trust’s objectives in the areas of finance, business development and workforce. The Quality and Governance Committee ensures operational and clinical risks are identified, measured and adequate controls are in place to provide the Risk Management Committee with the necessary assurances.

Reports of the risk review group are presented to the Quality and Governance Committee, which is the committee responsible for reviewing controls to manage the risk, ensuring that an appropriate risk treatment plan is in place and that the risk is assigned to a manager with the appropriate resources to control the risk. The Quality and Governance Committee seeks to ensure that all controls are based on an active consideration of the options for controlling risk to an acceptable level and that the control measures continue to be effective and represent best value for money. Reports on the risk register are included in the reports of the Finance and Activity Committee and Quality and Governance Committee, which are presented to the Trust Board.

The processes for managing principal risks are an important element in the Assurance Framework. The Finance and Activity Committee has overall responsibility for ensuring the effective management of principal risks in the Trust.

Each principal risk has an Executive Director lead who is responsible for formally reviewing the risk on a quarterly basis and by exception on a monthly basis. Any weakness in control measures, or inconsistent application of controls identified as a result of assurance activity is considered. Collectively, the Executive Team, on behalf of the Trust Board, has overall responsibility for managing principal risks and monitor risk treatment plans to ensure that principal risks included in the Trust Risk Register are effectively managed. The Executive Directors take collective responsibility for monitoring and reviewing the processes for the effective management of principal risks, and ensure that the Trust Board is kept fully informed of all principal risks. The quarterly principal risk report is signed off by the Executive Directors before it is presented to the relevant committee and Trust Board.

The Quality and Governance committee has a responsibility to oversee the effective management of the principal risks which threaten the delivery of the Trust’s principal objectives in the areas of customer focus, governance and workforce. The Quality and Governance Committee also has a responsibility to advise the Board of any operational risks that they consider pose a threat to the delivery of the principal objectives. The Board reviews these risks and determines whether to add them to the principal risk register.


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The Executive Director Lead determines the controls that are required to manage the principal risks. Once these are approved by the Trust Board they form the register of controls.

The Trust Board determines the assurances it needs to have confidence that the controls it has determined are in place and operating effectively. These form the register of assurances. The Trust Board delegates responsibility for receiving assurance on the effectiveness of the controls to its committees. Each committee is instructed on the assurances it is expected to receive and the date by which it is expected to receive them. The Assurance Framework register is updated with the reports of the committees on the receipt of assurances.

The Audit Committee has responsibility for reviewing the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the Trust’s activities. It does this by receiving regular reports on the assurances that are due to be received, the positive assurances that have been received, the negative assurances that have been received and any failure to provide assurance in accordance with the agreed timetable. The Audit Committee also receives any assurances which have been delegated to it by the Board and reports from internal audit, external audit and others on the systems of internal control.

The Audit Committee prepares a report to the Board after each of its meetings on:

• the effectiveness of the system of integrated governance, risk management and internal control,

• areas where controls need to be strengthened to ensure that principal risks are being managed effectively,

• areas where new assurances are required,

• The appropriateness of disclosure statements such as the Annual Governance Statement and declarations of compliance with Registration outcomes.

The Board uses the reports of the Audit Committee to obtain assurance about the effectiveness of the system of integrated governance, risk management and internal control, and to obtain assurance that disclosure statements are appropriate.

Operating in this way the Assurance Framework allows the Trust Board to review the internal controls in place to manage the principal risks and to examine the assurance mechanisms which relate to the effectiveness of the system of internal control. With this information the Board is able to address gaps in control and assurance.

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Managing and controlling risks related to information is a key element on the risk and control framework. The Information Governance (IG) Toolkit, a tool by which the Trust assesses its compliance with current legislation, Government directives and other national guidance, is a key part of the organisation’s Assurance Framework. The Trust progressed its action plan to improve performance in the areas of Information Governance management and Information Security assurance, and successfully achieved level 2 compliance at year end.

The Assurance Framework has identified that the organisation has a sound system of internal control with no significant control issues. Auditors have concluded that “an Assurance Framework has been established which is designed and operating to meet the requirements of the 2011/12 Annual Governance Statement and provides reasonable assurance that there is an effective system of internal control to manage the principal risks identified by the organisation”.

in addition, based on the work undertaken in 2011/12 the draft Head of internal Audit opinion is that “significant assurance can be given that there is a generally sound system of internal control, designed to meet the organisations objectives and that controls are generally being applied consistently”.

While there were no significant control issues, internal auditors did identify some weakness in the design and inconsistent

application of controls that put the achievement of particular objectives at risk. These related to compliance with the Trust’s Care Homes Financial procedures, incident reporting, review of Consultant Contract payments and Consultant Job Planning. Action is being taken to address these issues.

6. Statements and Declarations

6.1 Pension

As 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.

6.2 Equality and Diversity

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.


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6.3 Sustainability

The Trust has a Sustainable Development Management Plan in place which has been developed in response to the NHS Carbon reduction Strategy and continues to invest resources through its Discretionary Capital Programme to reduce energy consumption on an ‘invest to save’ basis.

The Trust will continue to engage with partners across Staffordshire in developing areas of best practice, environmental training, and seminars on new technologies in order to actively explore new initiatives in reducing the carbon footprint.

The Trust also has a working group in place that is focussing on the organisation moving towards becoming paper-light and improving ways of working in readiness for its move to a new corporate headquarters in 2012.

6.4 Information Governance Disclosures

All NHS organisations are expected to secure person identifiable data related to both patients and staff and to safeguard data holding systems and data flows. There have been no significant control issues related to data loss or confidentiality breach during the year ended 31 March 2012 and up to the date of approval of the annual report and accounts.

6.5 Corporate Governance Code

As highlighted in this document, the Trust has an established system of integrated governance, risk management and internal control across the whole of the Trust’s activities. The Trust therefore believes that it complies with the Corporate Governance Code.

7. Review of Effectiveness

As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review is informed in a number of ways. 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. Executive managers within the organisation who have responsibility for the development and maintenance of the system of internal control provide me with assurance. The Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. My review is also informed by the fact that the Trust continues to be registered under the Health and Social Care Act 2008 without conditions, and that robust processes are in place to ensure ongoing compliance with Registration outcome measures. There is also an annual performance assessment of Trusts conducted by the Care Quality Commission. My review is also informed by the work of the West Midlands and East Cluster, the NHS Litigation Authority, external assessments by organisations such as ROSPA and the British Safety Council, and the work of external audit and clinical audit, to ensure that the Trust is meeting the requirements of the Operating Framework for the NHS in England 2011/12 and is fully compliant with the CQC essential standards of quality and safety.

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The Board and its Committees consider and take action on the effectiveness of the system of internal control. Each level of management, including the Board and its sub committees regularly reviews the risks and controls for which it is responsible and takes action on the recommendation of assurance providers. These reviews are monitored and reported to the next level of management.

Principal objectives have been identified and the totality of assurance activity relating to the Trust’s principal risks has been reviewed within the assurance framework. Key controls are identified. The Board has mapped its assurance needs and identified sources for providing them. Independent assurance, from a wide variety of sources, is provided on the process of risk identification, measurement and management.

The organisation has in place arrangements to monitor, as part of its risk identification and management processes, compliance with other key standards covering areas of potentially significant risk such as Registration outcomes and the NHS Litigation Authority Risk Management Standards.

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 Quality and Governance Committee, the Finance and Activity Committee and the Audit Committee. I have also considered the work of Internal Audit throughout the year and the Head of Internal Audit Opinion on the overall arrangements for

gaining assurance through the Assurance Framework and on the controls reviewed as part of the internal audit work. A plan to address any weaknesses and ensure continuous improvement of the system is in place.

We recognise that good governance is a hallmark of high performing organisations. As mentioned in my statement, as part of the Board’s Development Programme we have completed the Board Governance Memorandum aspect of the Board Governance Assurance Framework (BGAF) that has been developed for aspirant Foundation Trusts. We are committed to building on our strengths and addressing any weaknesses as part of this process. As Accountable Officer, my review confirms that North Staffordshire Combined Healthcare NHS Trust has a generally sound system of internal control that supports the achievement of its policies, aims and objectives.

Fiona MyersChief Executive7th June 2012



Care Quality Commission (CQC) - The Care Quality Commission is the health and social care regulator for England looking at health and social care with the aim of ensuring better care for everyone in hospital, in a care home and at home.

Commissioning for Quality and Innovation (CQUINS) - are goals agreed with commissioners (cur-rently PCTs) to reward excellence by linking a proportion of providers’ income (what PCTs pay us) to the achievement of local quality im-provement goals.

Local Involvement Networks (LINks) - are made up of individuals and community groups, such as faith groups and residents’ associations, working together to improve health and social care services

NHS Midlands and East – is the Strategic Health Authority for the West Midlands and East of England. Strategic health authorities were created by the government in 2002 to manage the local NHS on behalf of the secretary of state. There were originally 28 SHAs. On July 1 2006, this number was reduced to 10. They are the key link between the Department of Health and the local NHS

Patient Environment Action Teams (PEAT) - is an annual assessment of inpatient healthcare sites in

England that have more than 10 beds. It is a benchmarking tool to ensure improvements are made in the non-clinical aspects of patient care including environment, food, privacy and dignity.

Primary Care Trust (PCT) – the or-ganisation responsible for assessing the healthcare needs of the local area and commissioning (buying) services.

Private Finance Initiative (PFI) - a partnership project bringing private sector funding and expertise into the running of health services

Stakeholder - A person or organisa-tion with an interest in a particular issue.

Statement on Internal Control (SIC) - An accountability document for public bodies to provide assurance that they are appropriately manag-ing and controlling the resources for which they are responsible. This is now known as the NHS Govern-ance Statements

The Trust – North Staffordshire Combined Healthcare NHS Trust.

Trust Board – The Trust Board has overall responsibility for the Trust’s activities.

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Appendix 1 – Glossary

www.combined.nhs.ukHarplands Hospital, Hilton Road, Stoke-on-trent St4 6tH

This document can be made available in different languages and formats including easy read on request. If you would like to receive the document in a different format please telephone freephone 0800 032 8728.

If you would like to receive this document in a different format please telephonefreephone 0800 032 8728 or write to our FREEPOST address:North Staffordshire Combined Healthcare NHS TrustFreepost MID25483Stoke on TrentST4 6B

The Trust is committed to providing communication support for service users and carers whose first language is not English. This includes British Sign language (BSL).

This document can be made available in different languages and formats, including Easy Read, on request.

If you would like to receive this document in a different format please telephone freephone 08000 328 728 or write to our FREEPOST address:

North Staffordshire Combined Healthcare NHS Trust Freepost MID25483 Stoke on Trent ST4 6BR

www.combined.nhs.uk

North Staffordshire Combined Healthcare NHS Trust Harplands Hospital, Hilton Road, Stoke on Trent ST4 6TH

The Trust is committed to providing communication support for service users and carers whose first language is not English. This includes British Sign language (BSL).This document can be made available in different languages and formats, including Easy Read, on request.