COUNCIL OF GOVERNORS ANNUAL GENERAL MEETING · 12. Membership Feedback Verbal For governors to...

COUNCIL OF GOVERNORS ANNUAL GENERAL MEETING The Annual General Meeting of the Council of Governors will be held at 10.00 am on Wednesday 24th September 2014, in the Lecture Theatre, Education Centre, Queen Elizabeth Hospital Presentation: Discharge Lounge – Carmel Majmudar, Matron and Erika Johnson, Junior Sister

A G E N D A 1. Apologies for Absence: 2. To Sign the Attendance Register: 3. Chairman’s Business 4. Minutes of the Previous Meeting Enclosure

To approve the minutes of the previous meeting of the Council of Governors held on Wednesday 21st May 2014

5. Matters Arising from the Minutes 6. Declarations of Interest Enclosure

To approve the updated Declarations of Interest of Mr Richard Thorold, Appointed Governor

7. Chief Executive’s Briefing Enclosure

To receive the Chief Executive’s routine briefing report Items for Decision:‐ 8. Annual Report and Accounts 2013/14 Enclosure

To receive the annual report and accounts for 2013/14, presented by the Chief Executive

9. Annual Management Letter 2013/14 Presentation

To receive the annual management letter presented by the Deputy Director of Finance

Items for Discussion:‐ 10. Membership Development Working Group Enclosure

To receive a progress report on the work of the Membership Group, presented by the Chairman of the Group

11. Governor Activities Enclosure

To receive a report on the activities of governors, presented by the Trust Secretary

12. Membership Feedback Verbal

For governors to feedback on events attended and activities undertaken, and to report any queries or comments received

Items for Assurance:‐ 13. Finance and Activity Performance Presentation

To receive a report on the Trust’s current performance, presented by the Director of Finance and Information

14. Monitor Q4 Return Enclosure

To receive the Q4 return and correspondence from Monitor presented by the Director of Finance and Information

15. Performance Report Enclosure

To receive the routine briefing report presented by the Deputy Chief Executive

Items for Information:‐ 16. Election Timetable Enclosure

To receive the election timetable for the 2014 elections, presented by the Membership Co‐ordinator

17. Audit Committee Annual Report Enclosure

To receive the Audit Committee annual report, presented by the Audit Committee Chair

18. Open to Questions

The Chairman will open the meeting to questions from the floor 19. Chairman’s Closing Remarks

COUNCIL OF GOVERNORS Minutes of a the Council of Governors Meeting held at 10.00 am on Wednesday 21st May 2014, in Rooms 9 & 10, Education Centre, Queen Elizabeth Hospital Present: Mrs JEA Hickey Chairman Mr J Bolam Public Governor – Central Mr T Bryden Public Governor – Western Mr A Dougall Public Governor – Eastern Ms S Gallagher Public Governor – Central Mrs A Griniezakis Staff Governor Mr B Hewitt Public Governor – Central Mrs M Jobson Public Governor – Central Dr F Kanu Public Governor – Central Mr A Kumar Appointed Governor Mrs J Lockwood Public Governor – Western Professor K McCourt Appointed Governor Mr P Hopkinson Public Governor – Western Miss L Ritchie Public Governor – Western Mr A Sandler Appointed Governor Ms C Squires Public Governor – Western Mrs M Summers Public Governor – Western Mr I Stafford Staff Governor Mr R Thorold Appointed Governor In Attendance: Mrs D Atkinson Trust Secretary Mr S Atkinson Associate Director – Surgical Services Mr S Bowron Non‐Executive Director Dr J Bryson Non‐Executive Director Mr J Connolly Director of Finance and Information Ms M Darroch OD and Staff Development Manager (for item G/14/29 ii) Dr A Fairbairn Non‐Executive Director Ms S Gair Risk Management Facilitator (for item G/14/33) Mr P Harding Director of Estates and Facilities Mr M Henry Non‐Executive Director Mrs K Larkin‐Bramley Non‐Executive Director Mrs Y Ormston Deputy Chief Executive Mrs J Ward SafeCare Project Officer (for items G/14/24 and G/14/29 i) Mrs J Williamson Membership Co‐ordinator Apologies: Mrs E Adams Public Governor – Central Mr M Brown Non‐Executive Director Mrs F Butler Staff Governor Mrs A Ellinson Public Governor – Central Mr K Godfrey Medical Director Ms C Hesketh Associate Director – Medical Services Mr F Major Non‐Executive Director Mr M Pearce Appointed Governor Mrs S Pearson Associate Director – Strategic Transformation Programme Mr ID Renwick Chief Executive Professor T Waring Public Governor – Central

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Agenda Item Discussion and Action Points Action

by G/14/17

CHAIRMAN’S BUSINESS: The Chairman opened the meeting by asking if anyone present had any revisions to their declared interests. She welcomed Ms Christine Squires to her first meeting and informed the group that Ms Squires had replaced Mr J Rae on the Council of Governors. She also welcomed Mr A Kumar, appointed governor, to his first meeting. Mrs Hickey reminded the group that the Governors Development Day will take place on Wednesday 9th July. This will be a full day with a varied programme and further details will be sent out shortly. Mrs Hickey concluded her report by informing the group that this would have been the last meeting for Mr F Major, Non‐Executive Director, but unfortunately he was unable to attend. He has served on the Board for nearly nine years. She thanked Mr Major for his hard work and support for the Trust and agreed to pass on thanks from the Council of Governors to Mr Major.

G/14/18

MINUTES OF THE PREVIOUS MEETING: The minutes of the Council of Governors Meeting held on Wednesday 26th February 2014 were approved as a correct record.

G/14/19 MATTERS ARISING FROM THE MINUTES:

The Action Plan was updated accordingly to reflect matters arising from the minutes. Mrs D Atkinson, Trust Secretary, reported that visits for governors to the Emergency Care Centre will be organised shortly. Mrs Hickey suggested that a pre‐meeting presentation on the discharge lounge be brought to a future meeting. She stated that the report on the theatres work will be brought to a future meeting when it is at a stage where on‐going work‐streams have developed further.

G/14/20 CHIEF EXECUTIVE’S BRIEFING:

Mrs Y Ormston, Deputy Chief Executive, presented the Chief Executive’s routine briefing report in the absence of Mr ID Renwick. She began by reflecting on the key headlines from the end of year report. She stated that the overall message is generally that the year had been difficult both financially and in service terms, with the cancer two week wait and A&E pressures, however the Trust is in a strong position overall thanks to the hard work of staff. Mrs Ormston continued reporting that achievements such as the unannounced CQC inspection in December 2013, the achievement and retention of Band 6 in the CQC’s ratings and other recognition and accolades demonstrates that we are a high quality

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organisation providing quality care. She then informed the group that the two year operational plan, on the agenda as item 20, was submitted to Monitor in April. She stated that directors of the Trust had a routine telephone call with Monitor recently to discuss the plan but the outcome was positive. She then stated that the next report to be submitted will be the five year strategic plan at the end of June. Mrs Ormston continued reporting on the C.Difficile target. She stated that at the year end 16 reportable cases (against the trajectory of 17) have been reported. However, for 2014/15, the trajectory has been increased to 24. This gives us greater tolerance but the Trust will continue to work towards a ‘zero tolerance’ approach. She continued her report giving an update on the corporate objectives. She reported that the building work for the Emergency Care Centre continues to be on schedule with lots of work on the new clinical pathways also progressing. The pathology hub is now complete and the process of installing and testing the new analysers and equipment is also well underway. Mrs Ormston then reported that the Trust received its formal invitation to join the Gateshead Health & Wellbeing Board and we have already attended two meetings. This will become increasingly important as the wider local agenda and particularly discussions on the Better Care Fund (BCF) develop. She concluded her briefing by reporting that the recent staff awards ceremony was a truly fantastic celebration. She stated that some governors were in attendance and the event was a humbling reminder of input and appreciation of care provided. After further discussion, it was: RESOLVED: to receive the report for information

G/14/21 FIT AND PROPER PERSONS DECLARATION:

Mrs D Atkinson, Trust Secretary, presented the new declaration (the Fit and Proper Persons Test) required by the Health Act 2012 and subsequently the Trust’s Standard Licence Conditions. The declared interests and Fit and Proper Persons Test are shown below:

Name Position Category Positive Responses

Eileen Adams Public Governor – Central A‐D None John Bolam Public Governor – Central A‐D None Tom Bryden Public Governor – Western A‐D None Alan Dougall Public Governor – Eastern A‐D None Anna Ellinson Public Governor – Central A‐D None Sheila Gallagher Public Governor – Central A‐D None Brian Hewitt Public Governor – Eastern A‐D None Paul Hopkinson Public Governor – Western A‐D None Gillian Huthart Public Governor – Central Response not received

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Margaret Jobson Public Governor – Eastern A‐D None Francis Kanu Public Governor – Central A‐D None Jacqueline Lockwood Public Governor – Western A‐D None Lynn Ritchie Public Governor – Western A‐D None Christine Squires Public Governor – Western A‐D None Mary Summers Public Governor – Western A‐D None Teresa Waring Public Governor – Central A‐D None Faye Butler Staff Governor A‐D None Sam Dae Staff Governor A‐D None Alison Griniezakis Staff Governor A‐D None Ian Stafford Staff Governor A‐D None Carole Turnbull Staff Governor A‐D None Dan Cowie Appointed Governor A‐D None Sarah Gascoigne Appointed Governor A‐D None John Hamilton Appointed Governor A‐D None Kath McCourt Appointed Governor A‐D None James Miller Appointed Governor A‐D None Mark Pearce Appointed Governor A‐D None Aron Sandler Appointed Governor A‐D None Richard Thorold Appointed Governor A‐D None

RESOLVED: to approve the Council of Governors’ Fit and Proper Persons Test

declaration

G/14/22 CHAIRMAN OF THE COUNCIL OF GOVERNORS’ REMUNERATION COMMITTEE:

Mrs JEA Hickey, Chairman, gave a verbal report to the group regarding the Chairman of the Council of Governors Remuneration Committee. She reported that the group will be aware that the Council of Governors delegates the Remuneration Committee with key decisions to make. She stated that the view of the Trust is that the committee should be chaired by a Governor but the view of Monitor is that this should be the role of the Trust Chairman or another Non‐Executive Director. Mrs Hickey reported that if she chaired the committee then conflicts of interest could arise. She stated however, that she attends part of the meeting to advise but doesn’t consider it appropriate that she should chair. She informed the group that it is their decision however, where we are not complying with the Monitor’s Code of Conduct, we need to explain. Mr R Thorold, appointed governor and Chairman of the Governors Remuneration Committee, stated that the committee had undertaken a long debate regarding the issue and considered the current arrangement to be appropriate. Mrs JEA Hickey reported that the draft guidance had stated that a Governor should chair the committee but after consultation it was changed to the Chairman or a Non‐Executive Director. After consideration, it was: RESOLVED: to approve that the Chairman of the Governors Remuneration

Committee will continue to be a Governor

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G/14/23 APPOINTMENT OF NON‐EXECUTIVE DIRECTOR:

She reminded the group that at its meeting in November 2013, the Council of Governors considered a paper on NED roles and responsibilities, including information on terms of office due to expire in June 2014. Arising from the recommendations in the report, the Council of Governors gave delegated responsibilities to the Governors’ Remuneration Committee to oversee a process for the appointment of one NED to replace Mr F Major. She reported that the Appointments Panel met on 14th May to interview six applicants from 20 applications received. The agreed recruitment process was followed and the panel was composed of the Chairman, three public governors and two staff governors. Mr ID Renwick, Chief Executive, and Miss K Forsyth, Head of Personnel, were also in attendance throughout the interview process, but did not take part. Following the interview process, the unanimous recommendation of the Panel is to offer the post of Non‐Executive Director to Mr John Robinson. Mr Robinson has recently retired from his post as a Strategic Director for Gateshead Council and has over 40 years of experience in the public sector. The panel was particularly impressed that Mr Robinson had reapplied for the position, having come a close second in last year’s recruitment round. In accordance with paragraph C.2.2 of Monitor’s Code of Governance, the appointment should be for a period of no more than three years. Therefore, to comply with this and to be consistent with the Trust’s process for NED succession planning, it is recommended that the appointment is for three years effective from 1st July 2014, to expire on 30th June 2017. Mrs Hickey thanked the panel for their time and input and expressed her pleasure with the appointment from a strong field of candidates. She stated that the group had undergone a long debate due to the high standard of candidates. After consideration, it was: RESOLVED: to approve the appointment of Mr John Robinson to the post of Non‐

Executive Director for the period 1st July 2014 to 30th June 2017.

G/14/24 QUALITY ACCOUNT 2013/14:

Mrs J Ward, SafeCare Project Lead, presented to the meeting a statement for approval by the Council of Governors on the Trust’s Quality Account 2013/14. She reminded the group that they had been given a draft copy of the full report in May 2014 and asked to forward any comments on the document to the Head of SafeCare. She read out the draft statement to the group and advised that one comment had been received from governors. After further consideration, it was: RESOLVED: to approve the statement for inclusion in the Trust’s Quality Account

2013/14

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G/14/25 MEMBERSHIP DEVELOPMENT WORKING GROUP:

Mrs D Atkinson, Trust Secretary, gave an update of the work of the Membership Development Working Group. She informed the meeting that Dr F Kanu, public governor, will be the new Chairman of the group from September 2014. Mrs Atkinson drew attention to the paper, agenda item 11, highlighting the membership totals and recent work of the group. She updated the group on the membership totals and the recent work of the group. She reported that the group continued to discuss community engagement events and stated that governors had attended a few events recently, including events in Whickham and Eighton Banks. Mrs Atkinson continued reporting that the next event will be the Teams Fair being held on 14th June where staff will also be attending from maternity, paediatrics and St Bedes and she asked for other governors to attend. She informed the group that a script is given to governors in attendance to assist in discussions and also for governors to gain feedback to the Trust on issues. After further discussion, it was: RESOLVED: to receive the report for assurance and information

G/14/26 GOVERNOR ACTIVITIES:

Mrs D Atkinson, Trust Secretary, presented a paper outlining future reporting of governor activities. She stated that as governors are participating in recruitment or engagement events to carry out their role, it is useful to have a regular update of events and activities in which they are involved. Mrs Atkinson drew attention to the paper, agenda item 12, and informed the group that a report will be brought to each Council of Governors meeting reporting on the activities and events. Governors are also encouraged to complete an online survey after attending an event to give feedback and comments. These comments will be included in the activities report to the Council of Governors. Mrs J Williamson, Membership Co‐ordinator, agreed to share the link to the online survey for completion by governors. After consideration, it was: RESOLVED: to receive the report for information

JW

G/14/27 MEMBERSHIP FEEDBACK:

Mrs J Lockwood, public governor, gave thanks to staff who take time out to allow

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governors to visit their departments. She stated that she has attended a number of visits recently and found them not only interesting and informative but helpful to see the logistics behind the ‘front line’. Mrs A Griniezakis, staff governor, stated that she finds that other staff members don’t know that she is a staff governor and asked if it would be possible to have a name badge. Mrs D Atkinson, Trust Secretary, agreed to look into this. Professor K McCourt, appointed governor, reported that an information board has been put up at the university and membership information has been included on it. Mr B Hewitt, public governor, stated that along with Mrs M Jobson, public governor, he had attended a membership recruitment event at Felling Health Centre. Although the day was quiet it went well so they will go again. Mr J Bolam, public governor, expressed his thanks to the staff who had been involved in the visits programme. He stated that he found the visits very interesting, especially the bowel screening hub. Mrs M Jobson, public governor, stated that a lot of people who she speaks to while recruiting are interested in the Medicine for Members sessions. She asked if the free parking for the event could be publicised more as this could encourage more to attend. Mrs D Atkinson, Trust Secretary, agreed to include this in the invitation and confirmation letters that are sent out to members. Dr F Kanu, public governor, asked if it is permissible to go to into wards or departments to recruit patients. Mrs D Atkinson, Trust Secretary, stated that no, this is not appropriate due to infection control or restrictions on wards. Governors have not undertaken a health check, whereas volunteers on the wards have. Mr A Dougall, public governor, also commented that he had enjoyed the visits he had taken part in. He said the staff are excellent and he was made to feel welcome Ms S Gallagher, public governor, reported that she had attended the community meeting at Birtley Hub and felt that the presentation and attendance by governors was well received. She congratulated Mrs M Jobson, public governor, for her presentation on the evening and stated that she had received a volunteering request, which she had passed on. Mrs M Summers, public governor, reported that she had been part of the judging panel for the staff awards and thoroughly enjoyed the awards evening.

DA DA DA

G/14/28 GOVERNORS’ FINANCE TRAINING:

Mrs J Williamson, Membership Co‐ordinator, gave a presentation to the group on a new online training course on NHS finance. She explained to the group that, as part of the development programme, governors are being given the opportunity to undertake finance training via an online eLearning package. Mrs Williamson gave an overview of the eLearning explaining that the software is aimed at staff with no financial experience and can be accessed via a website link on any computer with an internet connection.

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She stated that governors will be able to access up to five of the modules, however only one of the modules is compulsory; Introduction to NHS Finance. Mrs Williamson showed the group a number of screenshots of the software and explained the set‐up of the training. She concluded her presentation by explaining that at the end of each module users will be required to undertake a brief assessment and achieve a pass mark of at least 80%. Dr F Kanu, public governor, commented that the training sounds like a good idea as this may help with understanding the finance reports at meetings Mr P Hopkinson, public governor, asked if the marking of the modules is shared with the governor undertaking the training or with a member of staff within the Trust. Mrs D Atkinson, Trust Secretary, stated that the marking is only shared with the person undertaking the training. Trust staff are only notified once the module has been passed. After further discussion, it was: RESOLVED: to receive the presentation for information

G/14/29 NATIONAL SURVEYS:

i) NATIONAL PATIENT SURVEY

Mrs J Ward, SafeCare Project Officer, gave a presentation report on the Picker Inpatient Survey 2013. Mrs Ward explained the survey activity and explained how the scores are formulated. She then gave details of the performance of the Trust. She gave an overview of the results explaining that this year the Trust was average on 56 questions, significantly better than average on 30 questions and significantly worse on no questions. Mrs Ward reviewed the good results stating that 81% of respondents rated their care as 7 or more out of 10 and 95% said the hospital room/ward was very or fairly clean. She outlined the scores where the Trust rated significantly better including the cleanliness of toilets and access to be able to store personal belongings safely. Mrs Ward read to the group some of the positive and negative comments received and then summarised the league table of scores. She concluded her presentation by reporting on the next steps including sharing the results with staff and looking at areas where an average score was achieved. Mrs A Griniezakis, staff governor, asked how the Trust had faired against other local Trusts. Mrs Ward responded stating that the Trust is benchmarked against others of the same size etc but we don’t know who. After further discussion, it was:

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RESOLVED: to receive the report for information

ii) NATIONAL STAFF SURVEY

Ms M Darroch, OD and Staff Development Manager, presented a briefing report on the NHS National Staff Survey 2013. She explained that the survey was carried out in October to December 2013 and involved sending a questionnaire to a sample of 850 randomly selected staff. Ms Darroch reported that the response rate was 50% and showed the results against other local Trusts. Eight of the Trust’s key scores were in the top 20% of acute trusts, with six above average, seven average, three below average and four in the bottom 20%. She then gave an overview of the Trust’s top ranking scores including staff feeling pressured in the last three months to attend work when feeling unwell and staff suffering work‐related stress in the last 12 months. Mr P Hopkinson, public governor, stated that it is great to see the Trust doing better in some areas but he is horrified that 1 in 3 are reported to be suffering from stress and 1 in 5 reported experiencing bullying or harassment. He commented that the bullying could be linked to the stress. Ms Darroch then reviewed the areas of the survey where the Trust was lowest ranked and reported on appraisal levels and contributions towards work improvements. She stated that a lot of work is on‐going around leadership development and appraisal levels. Mr P Hopkinson, public governor, asked what the current level of sickness absence is. Mrs Y Ormston, Deputy Chief Executive, responded stating that currently the sickness level is around 4‐4.5%. Ms Darroch continued reporting on the staff friends and family test element of the survey. She stated that this year the survey has provided ranked scores on the question: “If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation”. The Trust’s response rate was 69.70%. Dr F Kanu, public governor, commented that once the Emergency Care Centre is complete this figure could increase. Ms Darroch then reported on the local questions included in the survey highlighting the top three stressors; work pressures/demands, change and how it is managed and relationships at work. She gave an overview of the responses. She concluded her presentation by reporting on the key priorities for the coming year, including increasing staff appraisals, service improvement being integrated into day to day activities and continuing to implement the Health and Wellbeing strategy. She also gave details of the next steps. Mr P Hopkinson, public governor, asked if a comparison could be provided against perceived and reported responses. Ms Darroch responded stating that the Trust is aware of some issues for example harassment, as regular reporting of incidents to advisers and cases etc is received.

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Mrs JEA Hickey, Chairman, stated that numbers are small compared to what the survey would suggest and stated that these are discussed at the Human Resources Committee. Mr A Kumar, appointed governor, asked if there was a breakdown on the discrimination findings. Ms Darroch stated that there is a breakdown of four or five protected characteristics. However, these are very little in numbers and nothing is of great concern. The statistics are reported to the Equality and Diversity steering group and monitored there. Miss L Ritchie, public governor, asked if there is any leadership development available to staff. Ms Darroch responded stating that the Trust offers several levels of in‐house courses and also the NHS leadership academy. She stated that a report will be taken to the Human Resources Committee to highlight the achievements from this training. Mrs M Jobson, public governor, asked if the target was to improve staff appraisals to greater than 80% at the moment. She stated that an appraisal is something maybe that lower graded staff look forward to and could be demoralising if put to one side or cancelled. Ms Darroch responded stating that the Trust is aiming for 100% and there is a huge push to achieve this. The Trust will be implementing incremental progression and therefore staff need to have a timely appraisal. After further discussion, it was: RESOLVED: to receive the report for information

G/14/30 FINANCE AND ACTIVITY PERFORMANCE:

Mr J Connolly, Director of Finance and Information, presented the headlines at the year end. He outlined the key points for month 12 (March 2014) explaining that the operating surplus is approximately £600k behind the plan. This is a slight improvement from month 10. Mr Connolly explained that the restructure costs include severance and redundancy payments. In addition, the profit on disposal of Dunston Hill had been planned for this year but had not yet completed. Mr Connolly reassured the group that the Trust’s financial status is acceptable in the current environment. He stated that there are risks for the year however good agreements and positive discussions with the CCG along with cost improvement opportunities being identified and delivered will continue to make an impact. He concluded his report by stating that the overall performance in 2013/14 has been successful but the Trust has difficult challenges in the next financial year. Ms S Gallagher, public governor, stated that some Trusts are in a terrible position but asked whether governors have been given the information. Mr Connolly responded stating that he could not speak for all other Trusts but believed some Trusts did not share financial information so fully with their Council of Governors.

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Mr P Hopkinson, public governor asked at what point does the Trust gets to where we are budgeting to go into deficit. Mr Connolly stated that the operating plan detailed that the Trust had planned to make surplus this year and next year but at a lower level recognising the difficulties of delivering large CRPs. Mr Hopkinson continued asking if the Trust is now in operating deficit is it insolvent. Mr Connolly stated that there is a special measures regime and administration process in place for Trusts who are struggling and new guidance has been publicised. Mrs JEA Hickey, Chairman, stated that Trusts are able to run in deficit in the shorter term but still not be insolvent if there is sufficient liquidity. Mr T Bryden, public governor, asked if there is a risk that there are GPs who buy services from other Trusts, e.g. ENT from Newcastle. Mr Connolly responded stating that there are some services that Gateshead does not provide. However, 30% of Gateshead patients go elsewhere but this includes services that we do not provide. There are trends in certain areas due to geographical position but we also cover the catchment area of other Trust’s work. He continued reporting that plans are in progress to repatriate maternity and orthopaedic patients. Mr R Thorold, appointed governor, asked how the Trust had performed against the planned cost improvement programme. Mrs JEA Hickey, Chairman, responded stating that the CIP is behind on plans but will continue. Mrs JEA Hickey, Chairman, concluded stating that the overall performance as acceptable and that some plans not achieved this year should deliver in 2014/15. After further discussion and consideration, it was: RESOLVED: to receive the report for information

G/14/31 MONITOR Q3 RETURN:

Mr J Connolly, Director of Finance and Information, presented Monitor’s Quarter 3 Return (31 December 2013). He stated that the Trust’s ratings for Q1 were reported as:

• Financial Risk Rating – 4 • Governance Risk Rating – Green

Mr Connolly drew attention to the paper, agenda item 17, and highlighted the key risks that had been identified including performance against key targets and indicators, sustainability and CIP delivery. Following further discussion, it was: RESOLVED: to receive the report for assurance and information

G/14/32 PERFORMANCE REPORT:

Mrs Y Ormston, Deputy Chief Executive, provided the Council of Governors with an update on performance against national and local targets.

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She began her report by informing the group that cancer performance measures are still subject to validation. However, the Trust did not achieve this target for the end of Q4. Work is on‐going to look at a detailed action plan to recover the situation. Mrs Ormston reported that in February 2014, the Trust experienced increased demand in A&E at peak times which resulted in the month’s performance at 93.02%. In light of this additional funding increased the front line operational resource to support existing staff and this has subsequently reversed the trend resulting in a month end position of 97.46%. She informed the group that the Trust initially reported 20 confirmed C.Difficile cases against the trajectory of 17. However, seven of these cases were submitted to the local appeal panel and four were upheld, giving a final out‐turn of 16 reportable cases against the trajectory of 17. Mrs Ormston concluded her report by stating the percentage of Personal Development Plans (PDPs) has increased significantly to 77%, and the Trust has now achieved 80% at the end of March 2014. Mr R Thorold, appointed governor, asked why there had been an increase in the C.Difficile target. Mrs MacArthur, Director of Nursing, Midwifery and Quality, stated that a time period is taken from the previous year to set the yearly target. However, even though the target has risen the Trust will continue to work to replicate this year’s performance. She stated that there were no reported cases in April and none in May so far. After consideration, it was: RESOLVED: to receive the report as assurance against the management governance

indicators in the Compliance Framework and local supporting measures of improvement management

G/14/33 COMPLAINTS, LITIGATION, INCIDENT AND PALS (CLIPA) REPORT SUMMARY:

Mrs S Neale, Risk Management Facilitator, presented to the group the findings from the CLIPA report covering 1st July to 31st December 2013. She drew attention to the report, agenda item 19, and highlighted the key areas. She informed the group that the Datix system has been upgraded and this will enable the system to better code reports. There is also an actions module which will monitor and manage the system to enable more learning to be accessed. Mrs Neale reported that the Trust had received 121 complaints from July to December 2013 which is similar to previous years. Three requests were also received from the Health Service Ombudsman. She gave an overview of the main reasons for complaints including x‐ray abnormalities where learning is being shared across the region and the usage of a private ambulance if internal ambulance is not available. Mrs JEA Hickey, Chairman, stated that she finds the reports and the learning points really valuable.

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Mrs G MacArthur, Director of Nursing, Midwifery and Quality, reported that the Trust is required to produce six‐monthly reports to the commissioners on the duty of candour. This will be included in future CLIPA reports. After consideration, it was: RESOLVED: to receive the report for information

G/14/34 OPERATIONAL PLAN 2014/16:

Mrs Y Ormston, Deputy Chief Executive, presented the Trust’s Operational Plan for 2014/16. She stated that the plan reflects the discussions from the governors’ workshop held in January 2014. Mrs Ormston drew attention to the report, agenda item, 20, highlighting the financial indicators where there is a considerable pressure around delivering income generation. She reported that with regards to non‐emergency activity, the Trust is looking at alternative ways of dealing with patients including ambulatory care. Previously patients would have been admitted but we are now trying to deal with and discharge back to GP for management. Mrs Ormston outlined two models of care including working with the CCG and nursing homes with the aim to try and maintain people in their home settings. The other was a diabetes model that includes consultants going to GP practices to provide shared care. She concluded her report by informing the group that the next document to be produced will be the five‐year strategic plan. After consideration, it was: RESOLVED: to receive the report for information

G/14/37 DATE AND TIME OF NEXT MEETING:

RESOLVED: that the next meeting of the Council of Governors will be held at 10.00

am on Wednesday 24th September 2014 in the Education Centre, Queen Elizabeth Hospital

Actions from Council of Governors Meetings

Date of Meeting

Minute Reference Action Lead Current Position

21/05/2014

G/14/28 Finance training has now been offered to all governors. So far 10 governors have registered for the module.

21/05/2014 G/14/27 Name badges for governors DA All governors will be issued with a name badge

26/02/2014 G/14/03 Arrange visits for governors to the Emergency Care Centre

DA/JW Visits to be arranged in October 2014

26/02/2014 G/14/08 Further information on the Discharge Lounge to be brought to a future meeting

IDR

Presentation arranged for 24/09/2014

20/11/2013 G/13/68 Update from meeting with Dr Mike Prentice, Medical Director for NHS England to discuss plans regarding the Emergency Care Centre and the Keogh review.

IDR Report to be brought to a future Council of Governors

21/11/2012

G/12/50

Report on theatres productivity work to the Council of Governors

IDR Report to be brought to a future Council of Governors

21/11/2012

G/12/54

To regularly update the Council of Governors on any Trust news

DA/JW On‐going

Paper for Council of Governors Meeting 24th September 2014 Agenda Item: 6

G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T

Declaration of Interests Background: In accordance with section 20 of Schedule 1 of the Health & Social Care (Community Health and Standards) Act 2003 NHS Foundation Trusts are required to maintain a register of Directors’ and Governors’ interests. This requirement is also enshrined in section 10 of the Trust’s Constitution. Any amendments to declarations must be declared following the change occurring and recorded in the minutes. The amended declared interests of Mr Richard Thorold, appointed governor, are shown overleaf as Appendix 1. The register for Gateshead Health NHS Foundation Trust is held at Trust Headquarters and is available to the public through the Trust Secretary. Recommendation: The Council of Governors is asked to note and record in the minutes the amended declared interests of Mr Richard Thorold, appointed governor. Mrs D Atkinson Trust Secretary

Appendix 1

Gateshead Health NHS Foundation Trust

Amendments to Register of Council of Governors’ Interests 2013/2014

Name Position Interest Interest of Spouse Category

Mr Richard Thorold

Appointed Governor

Owner and Director of Emarit Owner and Director of ICOVES Director of Gazelle Foundation

None

A, B A, B A

Key to Interests Declared: A Directorships, including Non‐Executive Directorships held in private companies or PLCs (with the

exeption of dormant companies). B Ownership or part ownership of private companies, businesses or consultancies likely or possibly

seeking to do business with the NHS C Majority or controlling shareholdings in organisations likely or possibly seeking to do business with

the NHS D A position of authority in a charity or voluntary body in the field of health and social care E Any connection with a voluntary or other body contracting the NHS service F To the extent not covered in the declarations above, any connections with an organisation, entity

or company considering entering into or having entered into a financial arrangement with the Trust but not limited to, lenders or banks.



CHIEF EXECUTIVE’S REPORT

This paper provides a brief update on some of the key issues and events for the Trust since the last Council of Governors meeting. Emergency Care Centre Work on the completion of the new ECC has continued since our last meeting, and both the interior and exterior of the building are starting to take shape. Following some minor delays to the timetable – which are, to some extent, inevitable in a project of this size and complexity – we currently anticipate handover from Millers on or around 24th November 2014. The building will then need to be thoroughly cleaned and the process of familiarisation for staff who will transfer into the ECC will begin in earnest. This should allow the new building to become operational sometime between Christmas and early in the new year, subject to service demands and pressures. At the same time, alongside the opening of the ECC Trust is looking at its freedoms as a Foundation Trust to look at innovative and exciting models for the future management and operation of the building. Pathology Centre of Excellence Since the last meeting, the Pathology hub has opened, with services for the three South of Tyne FTs now being provided by the newly integrated service. It is becoming increasingly clear that this particular development has the potential to open up a whole range of opportunities for the Trust, regionally, nationally and possibly even internationally, and the team is currently working on a Marketing Strategy to scope these. CCG Merger At the end of July, the CCG Alliance received formal confirmation from DoH that its application to formally merge with effect from 1st April 2015 had been approved. We are working closely with our CCG colleagues to understand what the merger means for them as Commissioners, and consequently what the impact on the future shape of healthcare services for Gateshead, and on the QE specifically, might be. Alongside this, the Trust has also had the benefit of its first round of meetings as a member of the Gateshead Health and Wellbeing Board. Since we became a member at the beginning of the financial year, Chairmanship of the HWB has transferred to Cllr Lynne Caffrey, and I recently had an induction meeting with her to explore our view on the key priorities for the group and where the QE fits into delivering those. I will keep the Council informed of the work of the Board in future updates. Financial Position Whilst our performance against core standards and targets remains strong, our emerging financial performance begins to be the cause of some concern. A combination of underperformance against some income streams, pressures against delegated budgets, and slippage in the implementation of cost improvement and transformational plans have generated an adverse performance against our financial plan in the early months of the year.

Efforts to reverse the position in all three of these areas are well underway, with the CIPs being a particular area of concern and focus for the Trust Board as a whole. Further detail is available in the Director of Finance’s update. Director Changes The Trust is currently experiencing what for us is an unprecedented amount of turnover amongst the Executive Director team. Whilst any turnover presents a period of uncertainty and risk for any organisation, the Board has been working hard over recent months to mitigate and minimise those risks:

• After a 24 year career at the QE, Gillian MacArthur retires from her post as Director of Nursing, Midwifery and Quality on 30th September 2014. However, her last working day was last Wednesday, from which time Hilary Lloyd (who many of you will know as our Deputy Director of Nursing) has taken up the role permanently following her successful appointment to the post.

• Also on 30th September 2014, we will wish a fond farewell to Yvonne Ormston, who has been appointed as Chief Executive of the North East Ambulance Service. Interviews for Yvonne’s replacement are being held tomorrow, and we have a strong field of seven candidates (from a field of 44) coming for interview.

• Following the departure of Jon Connolly at the end of June, John Maddison has joined the Trust as its new Director of Finance and Informatics. John has many years’ experience as a Finance Director in the acute FT sector both locally and further afield, and is already proving to be a strong addition to the director team.

I am sure you will wish to join with me in wishing all of our outgoing colleagues thanks for all of their work in support of the Trust, and upholding its core Vision and Values, and good luck and best wishes for their future challenges. And at the same time, welcome our new faces to the Executive team, and wish them well in helping us navigate the inevitable challenges, and exploit the many opportunities which we will inevitably face over the coming months and years. Ian Renwick Chief Executive September 2014



Annual Report and Accounts 2013/14

Purpose of the report: NHS Foundation Trusts are required to provide information on their performance and achievements annually. The annual narrative for the full year 2013/14 together with the statements of internal control was laid before Parliament in July 2014, as required by the Health and Social Care (Community Health and Standards) Act 2003. Once the Annual Report had been laid before Parliament, approval was given by Monitor for publication. A single document, the Annual Report narrative, together with the annual accounts for Gateshead Health NHS Foundation Trust is available on the Trust’s website http://www.qegateshead.nhs.uk/trustreports. A copy of the document is attached. As with previous years, a document has been produced to summarise the successes of the Trust for the full year 2013/14. This document has been distributed to all Trust members. Recommendation: The Council of Governors is asked to accept the Annual Report and Accounts. Mr ID Renwick Chief Executive

Annual Report and Accounts 2013/14

3

Gateshead Health NHS Foundation Trust Annual Report and Accounts 2013/14 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006

5

Contents

Chairman and Chief Executive’s Statement 7

Strategic Report 9 Introduction 9Overview of Trust Strategy 9Risks Uncertainties and Challenges 10

Overview of Trust Business 12 Operational Performance 12Financial Performance 22Patient Care 28Other Matters 30

Directors’ Report 39 Public Interest Disclosures 39Governance Report 41Remuneration Report 47Council of Governors 51Disclosure of Corporate Governance Arrangements 59

Quality Account 64

Annual Accounts 189

7

Chairman and Chief Executive’s Statement

Welcome to the Annual Report for Gateshead Health NHS Foundation Trust for the 2013/14 financial year. This report covers another period of change across the whole of the NHS and in our own Trust here in Gateshead. Throughout the past year the attention of the board and all our colleagues across the organisation has remained firmly focused on patient care and making their experiences central to everything we do. This vigorous focus on putting the patient at the centre of our work is continuing to ensure that we are able to provide quality and excellence to the people of Gateshead and the wider North East. The 2013/14 financial year has seen some real highlights for the Trust, most notably in the results of an unannounced inspection from healthcare regulator the Care Quality Commission (CQC). The results of this important inspection have been very pleasing, with the Queen Elizabeth Hospital (QE) receiving praise for all of its services and the CQC not identifying any recommendations for improvement for the hospital. Their judgements on care, treatment and support at the QE, along with their praise for the feedback systems that are in place, should be a source of real pride for local people. I was also pleased to see that the central role played by our dedicated and hardworking staff was rightly praised by the CQC, but also highlighted by the enthusiastic feedback from patients who were involved in the inspection process. During the year we were also delighted to be awarded a Band 6 rating, the highest possible, from the CQC and we maintained this level in the second set of ratings. We are acutely aware that our employees are both the face and the heart of this organisation and it is their hard work that adds real value to these achievements. In recognition of this, in April we held our second Staff Awards evening at which we celebrated the excellent contributions made by our staff. The number and standard of nominations were really encouraging and the tributes paid by patients and colleagues should give us all a great sense of pride. It has also been a year where many of our plans for the future have started to become a reality. Work is now well underway on the exciting new £32m Emergency Care Centre which is due to open in Autumn 2014.This innovative new facility will not only provide a state‐of‐the‐art unit right here in Gateshead but will also revolutionise the patient experience during medical emergencies. Patients will have greater dignity because they will not need to be moved long distances across the hospital for treatment and will also experience improved surroundings with single bedrooms and bathrooms. In addition, during 2014/15 we will be taking over the management of the local walk‐in centres on both the QE site and at Blaydon, providing a more integrated and holistic healthcare service in Gateshead. The new £12m Pathology Centre is another exciting development for the Trust and is the culmination of our collaboration with colleagues in South Tyneside and Sunderland. This world class facility, which will open shortly, will process all ‘cold’ tests for the three local trusts, as well as urgent QE tests and the lab work for GPs across the area. This is an important development for Gateshead and will be key to achieving some of our financial aims in the coming years. However, health services across the UK are facing times of unprecedented change and challenge. This is no different in Gateshead and in real terms the Trust will be looking to save around £8.4m in the next financial year. We should not underestimate the scale of this challenge which will require significant transformational change to reduce costs and increase our income streams. Our well‐ established approach to lean working and service redesign gives us an excellent platform to address this challenge.

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Strategic Report

Introduction In January 2015, the Trust will celebrate its 10th year as a successful Foundation Trust. Prior to becoming a Foundation Trust we were known as Gateshead Health NHS Trust. We provide an extensive range of services to the local population of 200,000 residents within Gateshead and people in surrounding areas who choose to access our services. We seek to be the provider of first choice to our local communities and also continue to develop our reputation for delivery of high quality specialist services, well beyond Gateshead boundaries. The Trust has an income of around £202m per year and is an employer of over 3300 staff many of whom live locally. The Trust plays a significant role in the local economy and, as such, has the potential to impact positively upon the health status of the local population. Whilst services are provided principally from the Queen Elizabeth Hospital, increasingly we deliver services in offsite, secondary care outpatient facilities including QE Metro Riverside, Blaydon Primary Care Centre and Bensham Hospital. Clinics operate at other primary care settings across Gateshead as well as beyond the Gateshead boundary in Washington and South Tyneside. Our regulated activities include: • Treatment of disease, disorder or injury • Assessment of medical treatment for persons detained under the Mental Health Act 1983 • Surgical procedures • Diagnostic and screening procedures • Maternity and midwifery services • Termination of pregnancies • Family planning

Our vision and values In 2008, the Trust introduced its vision for healthcare in Gateshead. The vision, developed through discussion with staff, reflects a set of core values that are maintained and protected as a Foundation Trust and the patient, and particularly the quality and safety of their care, is placed at its very heart. In 2013/14 the vision continues to provide a focus through which we deliver the best in safe, high quality care, underpinned by sound values and commitment to both patients and staff. For further information about Gateshead Health NHS Foundation Trust, please visit our website www.qegateshead.nhs.uk

Overview of Trust Strategy At the heart of our strategy is the provision of patient care of the highest quality to the population of Gateshead, and further afield, with the patient at the centre of everything we do. We are a Trust at the heart of the local community, and we provide core acute services to the people of Gateshead. We are one of the largest employers in the borough, and, as such, our network and profile goes beyond looking after people when they are unwell.

10

Our record for achieving excellent quality standards is shown through various external assessments, including the recent inspection by the Care Quality Commission (CQC), where the outcome was overwhelmingly positive; our Band 6 risk rating (the best possible) from the CQC; the extremely positive results from patient surveys and our status as a holder of an Investor in People gold award. We know that the public and our patients have very positive associations with the ‘QE’ and so we are building our brand around the QE, and the quality and excellence in healthcare we provide. We seek to be the provider of choice locally, and to continue to develop our reputation for delivery of high quality specialist services, well beyond the Gateshead boundary. These include specialist screening services and Gynaecology‐Oncology services to wider populations including South of Tyne and Wear, Northumberland and Humberside, Cumbria and Lancashire. A key component of our strategy involves building greater networks to provide sustainable, high quality services for our patients going forward. We recognise that the direction of travel for health and social care is greater integration, and we are working hard with colleagues within our unit of planning to achieve this, using mechanisms such as the Better Care Fund. We are excited to have been able to make capital investment into key assets, which will significantly enhance our services. Our new Emergency Care Centre will bring together many years of work to redesign patient pathways for those with emergency or urgent care needs, and will substantially improve patient experience. Our Pathology centre of excellence will bring cutting edge technology to diagnostics and will make a tangible difference to patient care. Our strategy sees us making the most of these new facilities, together with our Surgery Centre, into the future. Our business model is based on a Service Line Management approach, and we have recently re‐structured to ensure we are strategically positioned to face the challenges that the future will bring for acute hospital Trusts, and to deliver our strategic goals. We pride ourselves on being an innovative, forward thinking and responsive organisation, which is adaptable and flexible, and with the excellent networks and relationships to deliver the best care in the interests of our patients.

Risks, Uncertainties and Challenges The Trust’s service strategy is set within a period of rapid change within the local and national health care landscape, during an on‐going period of economic constraint in which there is no real financial growth for the NHS. This brings with it an atmosphere of risk and uncertainty which the Trust has analysed into key challenges and opportunities, discussed in detail in our operational plan, the principal ones being: • The predicted stepped change in the national age profile will result in increasing pressure upon our

services from patients with increasing co‐morbidities and dependencies. This challenge is linked with the need to manage capacity and demand across the local area and in particular should be addressed to some extent by the opening of the new Emergency Care Centre

• The economic downturn and national financial environment sets a financial context of uncertainty

and change which the Trust will need to respond to effectively • Government policy, setting the commissioning context and planning requirements which are

reflected in local commissioning priorities, signposts a clear shift towards investment from acute secondary care services towards primary‐care led and integrated service models. In particular the introduction of the Better Care Fund will drive forward service integration and the transfer of services from the acute setting to primary and community care. This brings with it further challenges relating to the pace of change, new funding models and the need to continue with high standards of care in a rapidly changing environment

11

• The wide ranging impact of the Keogh Report on emergency and urgent care and associated

diagnostic services. In particular the drive towards 7 day working and implementation of Keogh’s ten clinical standards, to improve patient outcomes at the weekend

• To further build upon the comprehensive framework of measures to ensure quality and patient

safety as endorsed by Francis, Berwick and Keogh. This encompasses patient and carer involvement in decision making, robust monitoring and measurement of the patient experience and clarity of roles.

• The increasing likelihood of competition both locally and nationally, from other acute trusts and

also the independent sector. The market is beginning to open up with the AQP programme and also nationally led service reviews such as stroke, maternity and IVF

The financial risks within the immediate planning horizon of two years are discussed in in detail in the financial overview later in this report. The tariff deflator, continuing cost pressures and the efficiency requirement all generate financial risks. The Trust continues to develop, however, and plan for the future in order to mitigate the risk where possible. The opening of both the Emergency Care Centre and the Pathology Hub in 2014/15 are key components of this strategy.

12

Overview of Trust Business

Operational Performance Meeting the Demands as Provider of Choice The graph below display our patient activity from April to March 2008‐2014

And the activity movements in these key areas are:

Activity Total 2008/09

Total 2009/10

Total 2010/11

Total 2011/12

Total 2012/13

Total 2013/14 Movement

Accident and Emergency Patients treated in Accident and Emergency (Type 1)

61,640 60,751 62,510 63,106 61,322 65,222

Patients treated in Accident and Emergency (All Types)

61,640 60,751 62,510 63,106 61,322 *74,133

Inpatient Activity

Patients treated as ordinary admissions 5,897 5,692 5,520 6,450 6,443 6,539

Patients treated in acute services and services for older people (FFCE’s)

38,905 40,306 47,612 58,987 59,987 57,105

Patients treated as day cases 4,397 5,449 13,653 23,646 24,405 24,843

Patients treated non‐electively (All FCE’s) 35,415 37,866 37,695 39,474 39,465 41,213

0100002000030000400005000060000700008000090000

2008/09 2009/10 2010/11 2011/12 2012/13

Inpatient & Daycase FCE's New Outpatient Attendnaces A&E Attendances

Patient Activity April‐March 2008‐2013

13

Activity Total 2008/09

Total 2009/10

Total 2010/11

Total 2011/12

Total 2012/13

Total 2013/14 Movement

Patients admitted as emergencies from Accident and Emergency

14,447 14,970 14,631 16,059 16,816 17,620

Outpatient Activity

Consultant led outpatients 154,568 155,954 154,967 153,663 143,953 148,192

Nurse led outpatients 163,454 174,436 164,046 160,298 143,544 154,982

Patients not attending for first consultant outpatient appointment

7.13% 7.08% 7.14% 6.81% 7.50% 6.66%

*Includes the Walk in Centre Activity Demand for Our Services Did Exceed our Expectations A&E Waiting Times The DoH national A&E waiting time standard is that 95% of patients should wait less than 4 hours in the department. In 2013/14 the Trust achieved this standard in every month with the exception of February. The winter of 2013/14 proved very challenging for the Trust with an unprecedented increase in the number of very sick and poorly patients requiring immediate unplanned acute care. There were occasions when the number of over 4 hour waiters peaked during the winter and these correspond with the significant increases in emergency activity, peaks in the numbers of patients arriving via ambulance and winter bed pressures.

*Includes the Walk in Centre Activity from October 2013

86.00%

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0

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2011/12 performance 2012/13 performance 2013/14 performance

14

The table below marks the increase in the total number of attendances and the impact on non‐elective pathways.

2008/09 2009/10 2010/11 2011/12 2012/13 2013/14

Patients treated in Accident and Emergency 61,640 60,751 62,510 63,106 61,322 65,222

*74,133

Patients admitted as emergencies through Accident and Emergency

14,447 14,970 14,631 16,059 16,816 17,620

% of A&E patients admitted to hospital 23.40% 24.60% 23.40% 25.40% 27.40% 27.02%

Total number of Emergency Inpatient Spells 28,784 29,337 28,666 29,615 29,859 28,840

*Includes the Walk in Centre Activity The Trust has seen and treated circa 3,900 more patients in A&E, representing growth of 6.39% in A&E attendances. All activity (which includes Walk in Centre patients) volumes have increased by 12,993 patients representing a 21% increase. Nearly one third of this increase is apportioned to non‐Gateshead residents; this type of activity shift demonstrates the pressure on Emergency Departments across the patch and more generally across the whole urgent care provision of services. Despite these pressures the Trust achieved compliance with the national 4 hour target in 2013/14. The table below represents our achievement and the patch‐wide pressures.

Attendances in A&E (Type I) Gateshead Sunderland South Tyneside Durham

Q1 97.60% 91.00% 95.70% 88.70% Q2 96.00% 92.60% 96.50% 90.20% Q3 96.00% 91.60% 95.80% 88.00% Q4 95.30% 91.90% 94.70% 86.30% 13/14 96.20% 91.80% 95.70% 88.30%

All Types including Walk in Centre Gateshead Sunderland South Tyneside Durham

Q1 97.60% 93.90% 98.70% 95.20% Q2 96.00% 95.10% 98.90% 95.70% Q3 96.90% 94.40% 98.50% 94.70% Q4 96.20% 94.40% 98.10% 94.00% 13/14 96.70% 94.40% 98.60% 94.90% Increased Demand for Access to Urgent Services & Treatments Cancer Targets In 2013/14 the Trust reviewed 7,412 patients who were referred urgently by their GP, where the GP has requested an appointment within two weeks. This growth represents a 13% increase on the previous

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16

Constantly striving to match expectations The patient right ‘to access services within maximum waiting times, or for the Trust to take all reasonable steps to offer patients a range of alternative providers if this is not possible’ remains in the NHS Constitution in England. The Trust continued to perform well against the RTT measures to ensure that patients are treated within 18 weeks from referral: • In the outpatient setting 97.4% of our patients started treatment within 18 weeks, exceeding the

national 95% expectation; • In the inpatient setting 94.3% of our admitted patients started treatment within 18 weeks, again

surpassing the national 90% expectation. The Trust has also delivered the 2013/14 operational standard that 92% of patients on an incomplete pathway should have been waiting less than 18 weeks. At the end of March 2014, 94.8 % of patients on an incomplete pathway had been waiting less than 18 weeks. Timely Access to Diagnostic Examinations Despite the increases in demand for our diagnostic services the Trust continues to perform extremely well in standards measuring diagnostic waiting times; 99.85% of our patients waited less than 6 weeks for a diagnostic test in 2013/14. The annual changes in the cumulative number of patients waiting for a test are exhibited below. Achieving Waiting‐Times and National Targets The Trust reports cancelled operations as defined by the Department of Health (DoH), i.e. operations that are cancelled for non‐medical reasons on the day due to be admitted to hospital. As a proportion of elective activity, this year’s performance was reported at 0.68%, which is within the 0.8% operational tolerance level. All of the patients who were cancelled were re‐admitted within 28 days following cancellation Lengths of Stay It is important for our patients at the QE to access care when and where they need it, but equally important to ensure that patients also do not stay any longer than they need to, avoiding any unnecessary delays in patients going home safely. Average Length of

Stay 2011/12 Average Length of

Stay 2012/13 Average Length of

Stay 2013/14 Movement

Totals 2.9 2.9 2.8

Elective 0.7 0.8 0.8

Non‐Elective 5 4.9 4.9

The table above demonstrates that overall our average lengths of stay are comparable to the previous year.

17

Older Persons’ Pathway Improvements The graphs below demonstrate our improvements in Older Persons average non elective lengths of stay. The reductions represent an average of 54 days less for our elderly non‐elective inpatients and an average of 75 days less for our patients being treated under the specialty of old age psychiatry.

The Urgent Care strategic plan recognises the challenges of a growing elderly population, and a historic over‐reliance on hospital emergency care. At the QE Gateshead we are passionate about providing patient centred coordinated care; which means providing more care around the patient and their individual health needs in their home as opposed to the traditional hospital based care model. In 2013 we embarked on our own integrated care pilot of acute geriatricians working into care homes in Gateshead where our geriatricians and old age psychiatry service support, care, and treat elderly patients in their own surroundings. This pilot supports our partnership framework to work with the wider care economy to fully develop and integrate our pathways in Gateshead. We look forward to strengthening our partnership arrangements and achieving excellent shared health outcomes in the coming year. Local Initiatives to Tackle Health Inequalities The Urgent Care 5 year strategic plan includes improving care co‐ordination and continuity of care with a greater focus on health prevention and effective re‐ablement services. Reducing unnecessary readmissions is our high‐level measurement of improvements made in this area. Reducing Avoidable Readmission to Hospital The table below demonstrates our improvements to the overall 28 day readmission rates. (Source Dr Foster).

Year Readmissions Super‐spells Our Rate National Rate

2010/11 4536 47482 9.55% 9.37%

2011/12 5337 57281 9.32% 9.01%

2012/13 5354 56830 9.42% 8.99%

2013/14 (April to Jan) 3001 33898 8.85% 9.78%

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MRSA The graph below demonstrates the improvements made over the last 6 years in reducing MRSA bacteraemia.

What does the Care Quality Commission Say about our care? The CQC regulate the quality of care provided in the Hospital; they do this by visiting the hospital to assess frontline service delivery and they use external intelligence (selected from up to 150 indictors) to assign a risk rating. The table below reflects risk ratings for Gateshead.

Date Risk Rating Outcome October 2013 0.57% Band 6 March 2014 2.15% Band 6

Although the risk rating increased in March 2014 the Trust was awarded a second ‘Band 6’ rating which means that Gateshead received the highest assurance for the delivery of health care. Venous Thrombus Embolisms The first Intelligent Monitoring report in October 2013 highlighted the ‘Proportion of patients risk assessed for VTE’ as a ‘risk’ with a rate of 91% (the required CQUIN rate was 95%). The performance assessment was based on a dataset from 01/04/13 to 30/06/13. Remedial follow‐up work to encourage staff to complete the risk assessments is now completed and there are currently no concerns; this data item was not flagged as a risk in the March 2014 report. Current Risk Rating The latest Intelligent Monitoring report highlights 2 elements of risk for secondary prevention medication following an MI, and the proportion of provider complaints.

‐0.07 ‐0.06

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2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14

% cha

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No. of cases

MRSA Bacteraemia

Number of MRSA Bacteraemia % change on previous year

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MINAP Data‐Set The National institute for Cardio Vascular Outcomes Research (NICOR) reviews and measures our hospital compliance against a suite of measures in the national service framework to improve the quality of care for heart attack patients. The data is collected monthly via the MINAP audit programme. Data extracted from 1st April 2012 to 31st March 2013 was highlighted as ‘elevated risk’. The trust did not comply with the 90% standard of eligible patients receiving secondary prevention medications for which they were eligible. The data submission was found to be inaccurate and not reflective of actual practice and a larger proportion of patients had received preventative treatment. The Trust was unable to re‐submit this data to reflect clinical practice. Measures are now in place to ensure that data submission is reflective of clinical practice. Provider Complaints The measure reviewing the ratio of complaints to patient volumes is higher than expected and has been identified as an elevated risk in the Intelligent Monitoring Report. This could suggest that our complaints service is well publicised and accessible, as the number of complaints made directly to the Care Quality Commission was found to be much lower than expected. The complaints process was inspected by the CQC in December, the inspection concluded that the process and the service was well run. Regulatory Ratings Report Our Annual plan predicted a Financial Risk Rating (FFR) for the year of 3 (where 1 is poor and 5 is excellent), with an Amber/Green governance rating; recognising the ambitious C.Difficile reduction in our local objective to report no more than 17 cases in 2013/14. The table below details quarterly performance and recognises the in‐year monitoring change in regulatory regime from the Compliance Framework to the Risk Assessment Framework, a description of the changes is detailed below. Annual Plan

2013/14 Q1

2013/14 Q2

2013/14 Q3

2013/14 Q4

2013/14 Compliance Framework

Financial Risk Rating 3 3 3

Governance Risk Amber /Green Green Green Risk Assessment Framework

Continuity of Services Rating 4 4

Governance Risk Green Green Annual Comparison Annual Plan

2012/13 Q1

2012/13 Q2

2012/13 Q3

2012/13 Q4

2012/16 FFR 3 3 3 4 4

Governance Risk Amber/Green Green Green Amber/Red Amber/Green

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Compliance Framework Application of Measures: Financial Risk 5 point risk scale where 5 represents little or no concerns, and 1 represents significant risk, and consideration for escalation. Governance Risk Green represents a service performance score of <1 i.e. little or no shortfall in under achievement of national measures, or not more than 1 target breached. Amber green is assigned when the performance score is greater than 2.0 but less than 4. A red rating is applied when a score of 4 or greater is accumulated.

Risk Assessment Application of Measures: Continuity of Services (Financial Risk) 4 point risk scale where 4 represents little evidence of concern or no risk assigned, and 1 represents significant risk, and consideration for escalation. Governance Risk Green represents no issues identified, or red where governance concerns have been identified and formal regulatory action is undertaken. Governance concerns are triggered by consecutive quarterly service breaches or concerns raised by third party reports/intelligence.

Quarterly Ratings Compared with the Plan In 2013/14 we anticipated an amber/green rating to reflect the governance risk of breaching the C.Difficile objective with an annual allowance of 17 cases; this target was always going to be a challenge representing a 23% reduction from the total number of unavoidable cases reported in 2012/13. This risk did materialise in year as the total number of cases reported initially did exceed the annual trajectory, however the findings from the local review panel deemed 4 of the cases reported were unavoidable; the Trust was therefore within the annual allowance, with no further risks to this indicator identified. In the first half of the year pressures were evident in the 2 week target; the Trust under performed in this area for 2 successive quarters. Patients choosing to wait longer for their initial appointment were the main contributory factor. This under performance was not reflected in the governance risk rating as the measure carried a weighting of 0.5 in the Compliance Framework, and the Trust regained compliance during Q3.

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Financial Performance Summary Financial Performance The Trust has returned a surplus in 2013/14 and despite not fully achieving its financial plan as set out at the beginning of the year, returned a Continuity of Risk Rating of 4. Additional income was received from commissioners, in recognition of increased services, particularly through the winter, which assisted in achieving this. Alongside this, plans were identified that largely delivered the efficiency target. The Trust has posted earnings before interest, tax, depreciation and amortisation (EBITDA) of £8.4m and achieved a surplus of £80k on income and expenditure once technical issues have been adjusted for. These are charges relating to restructuring costs and the revaluation of the estate in the form of asset impairment. This is detailed in the table below. Table 1: Summary Statement of Comprehensive Income for the year ended 31 March 2014

£000 Income 202,690

Operating expenses (216,241)

Operating Surplus/(Deficit) (13,551) Finance Income 77 Finance expense – Financial Liabilities (662) Finance expense – unwinding of discount on provisions (49) Public Dividend Capital dividends payable (2,774) Surplus/(Deficit) for the Financial Year (16,960) Impairments 15,966 Restructuring costs 1,073 Adjusted surplus 80 Continuity of service risk rating 4

Income reflects an increase of 6% over 2012/13 and expenditure, excluding impairments, increased by 9%. The planned deficit for the year was £7.4m (a £3.6m surplus excluding impairments and restructuring costs). The Trust actually made a deficit of £16.9m (a surplus of £80k excluding impairments and restructuring costs). A summary of the main reasons for the movement from the plan is shown in Table 2 below. Table 2: Summary Movement from Planned Surplus

£m Planned Surplus/(Deficit) (7.4) Net increase in clinical income 4.8 Increase in other income 2.6 Increase in costs, mostly associated with additional activity (8.1) Slippage in fixed assets impairments (4.9) Restructuring costs (1.1) Increase in depreciation (0.5) Decrease in non‐operating income (1.7) Increase in non‐operating costs (0.5) Actual Surplus/(Deficit) (16.9)

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Additional activity was performed during the year and the Trust received additional income in recognition of this. The Trust also did not realise income from the sale of land as planned, although this will go ahead in 2014/15, and incurred just over £1m in restructuring costs. The Trust needs to generate surpluses year on year to fund investment in future capital developments. The level of fixed asset impairment was less than planned due to the delay in opening the new Pathology Hub building in 2013/14. Technical Accounting Policy Changes 2013/14 The Trust prepares the accounts under International Financial Reporting Standards (IFRS) and in line with the HM Treasury Financial Reporting Manual, Monitor Annual Reporting Manual and approved accounting policies. The one significant change in accounting policies in 2013/14 has been to consolidate Gateshead Health NHS Foundation Trust Charitable Funds in to the accounts of the Trust following implementation of a previous deferral of IAS27 (revised) Consolidation of NHS charitable funds. Income The Trust received £202.7m in total income for 2013/14 with income from activities (core healthcare) totalling £177.6m. Of this £151.4m came directly from CCGs for the commissioning of patient care and a further £21.7m from NHS England through the area teams, for specialised services. Together these account for 97% of the Trust’s income from activities with 68% directly from the Gateshead CCG for the treatment of our immediate local population. An analysis of total income from activities is shown in Chart 1.

For 2013/14, the Trust’s income from private sources stood at 0.23% of total income, in line with previous years. Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) requires that the income from the provision of goods and services for the purposes of the health service in England must be greater than its income from the provision of goods and services for any other purposes. The Trust has met this requirement. Other major sources of income are identified in Chart 2.

Chart 1. Analysis of Income from Activities

Gateshead CCG

NHS England

Sunderland CCG

North Durham CCG

South Tyneside CCG

Foundation Trusts

Other CCGs

NHS Other

Other

Private Patients

NHS Injury Scheme

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Expenditure Total operating expenditure for the year totalled £216.2m which excludes the payment of Public Dividend Capital of £2.7m. An analysis of operating expenditure is shown in Chart 3, the main elements of this were: • Employee Expenses £133.1m (61.6%) • Fixed Asset Impairment £15.9m (7.4%) • Clinical Supplies and Services £19.2m (8.9%) • Drug Costs £14.0m (6.5%) • Premises £8.7m (4.0%) • Depreciation £4.3m (2.0%)

Chart 2. Analysis of Other Operating IncomeRecharged Staff costs

Training and education

Non‐patient care services to otherbodiesOther

Car Parking

Catering

Research and development

Clinical test services

Rental revenue from leases

Chart 3. Analysis of Operating ExpenditureServices from NHS Foundation Trusts

Transport

Purchase of healthcare from non NHSbodiesServices from other NHS Bodies

Employee Expenses

Drug costs

Supplies and services ‐ Clinical

Supplies and services ‐ General

Establishment

Premises

Depreciation

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The Trust has complied with the cost allocation and charging requirements set out in HM Treasury and Office of Public Sector Information guidance. This is relevant to areas such as Payment by Results, the mechanism by which the Trust receives the majority of its income from CCGs and the production of the annual Reference Cost Return. Better Payment Practice Code We continue to work towards compliance with the Better Payment Practice Code which requires the Trust to aim to pay all valid invoices by the due date of within 30 days of receipt of goods or a valid invoice. We have met this standard for 93.4% of invoices, detailed performance against the code can be found in the full accounts. Following a recommendation from government and Monitor, we also aim to pay small to medium sized businesses within 10 days of receipt of goods and services wherever possible. Capital Expenditure Capital expenditure for the year was £28.2m. Funding for the capital programme was made available from internal depreciation, the surplus from investment achieved in prior years, plus external funding from the Foundation Trust Financing Facility (FTFF) of £17.4m and Public Dividend Capital (PDC) of £7.7m. The two significant projects funded through this were the Emergency Care Centre and the Pathology Centre both of which will open in 2014/15. The general breakdown of the capital programme is shown in Chart 4.

Key Financial Risks The Trust has developed a financial plan for 2014/15 that sets out to generate financial performance that allows the Trust to deliver sustainable, high quality and safe services. For the Trust quality and financial viability are interdependent. There are four main financial priorities that are fundamental to delivery of the overall financial strategy: • Revenue generation; • Cost improvement as part of an efficiency strategy; • Managing liquidity; and • Excellence in financial governance.

Chart 4. Capital Expenditure

Buildings (excluding dwellings)

Assets under construction

Plant and Machinery

Transport Equipment

Information Technology

Furniture and fittings

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There are a number of key measures that will indicate the success of the financial strategy: • Maintain a quarterly Continuity of Services Risk Rating of 3; • Deliver an I&E surplus of at least £2m excluding technical adjustments; • Delivery of the cost improvement programme and revenue generation target; • Spend within limits of capital programme, delivering at least 75%; and • Achieve at least significant assurance from all internal audit reviews of fundamental systems. There are, however, some risks to achieving this planned surplus, key examples of which are outlined below. Activity Levels and Income The Trust has agreed contracts with all its main commissioners. It is therefore imperative that the Trust has robust monitoring and communication plans in place with the CCG to ensure neither the Trust nor the CCG are impacted upon detrimentally through significant changes in activities which do not reflect the experience nor activity plan of the Trust. The opening of the Emergency Care Centre in the autumn may affect activity levels in emergency care and again effective monitoring of this activity will continue to take place to ensure a smooth transition and robust activity and finance plan. Delivering the Efficiency Programme The Trust is facing the need in 2014/15 to deliver a significant efficiency programme of £6.9m as well as a £1.5m revenue generation target. The level of savings required will continue for the foreseeable future and is in line with efficiency requirement assumptions being used nationally. Delivering this level of savings will be extremely challenging, but despite this plans are being developed meet the challenge through the Trust’s Transformation Board. Financial Pressures and Inflation The Trust is reliant on sound financial management, particularly around operational budgetary control and the delivery of the efficiency programme, to ensure that it can manage pressures that arise in year. The current economic climate also creates uncertainty around potential expenditure pressures alongside the need to continually improve patient care and deliver high quality services. The Trust has included realistic estimates based on national assumptions when developing its plans for future years. Commissioning & Structural Changes The impact associated with transferring the commissioning of acute care to Clinical Commissioning Groups (CCGs) and other new commissioning organisations carried a level of risk to the Trust both in terms of services commissioned and prices paid. The impact of these structural changes has now settled, but the Trust remains mindful of the risks associated with the introduction of Any Qualified Provider (AQP) and how this could impact on services, consideration being given to all tender opportunities, in line with the Trust’s Commercial Strategy. The Better Care Fund will also have a significant impact on the Trust and the services it provides. Patient Administration System (PAS) The Trust went live in summer 2012 with a new PAS system. As the income to the Trust and reporting of performance information relies upon accurate recording and coding of data in the system, this was an obvious risk during 2013/14. Substantial and detailed work has been on‐going throughout the year in order to minimise the potential impact and risk associated with such a significant project. Capital The Trust is now nearing the end of a substantial capital programme in particular the new Pathology Centre which will open during the first quarter of 2014/15 and the Emergency Care Centre, due to be fully commissioned in the autumn. There remains some risk associated with the construction, in particular around slippage and cash flow planning.

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Accounts The full accounts are included at the end of this report. The Trust Board of Directors have a reasonable expectation that Gateshead Health NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, we continue to adopt the ‘going concern’ basis in preparing the financial accounts for the organisation. Audit of Accounts The accounts have been fully audited, and the appropriate certificate is included within the body of the accounts. The Board of Directors acknowledge their responsibilities for the financial statements included in this report. All of the accounting records have been made available to the auditors for the purpose of their audit and all transactions undertaken by the Trust have been properly reflected and recorded in the accounting records. All other relevant records and related information has been made available to the auditors. The Board is also satisfied that there are no issues arising since the Balance Sheet date that would materially affect the 2013/14 accounts.

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Patient Care The following section outlines in brief how the Trust is developing its services to improve patient care. Detailed information can be found in the Trust’s Quality Account 2013/14 pages 64 188. Emergency Care Centre ‐ Work is well underway on the Trust’s £32 million Emergency Care Centre which will transform the way local people will be cared for. It will combine the traditional accident and emergency, walk in centre, medical and surgical assessment and urgent children’s services all under one roof. This will make things easier for our patients as all of these services will share the same reception within the one building, where our fully qualified staff can make sure they are seen by the right member of staff. The Centre will also include a 25 bed short stay unit (all single occupancy en suite rooms) for adult patients who are able to be treated and sent home within a short space of time. These changes mean more dignity for emergency patients as they can be transported to the short stay ward within the centre, through specially designed routes not accessible to other members of the public. As well as the changes to our physical layout, there have also been changes behind the scenes with the QE taking responsibility for running the walk in centre at the QE from South Tyneside NHS Foundation Trust in April. QE Gateshead will also be running the walk in centre in Blaydon from June this year. Pathology – 2013/14 has seen the completion of the construction phase of the new Pathology Centre on behalf of the South of Tyne and Wear Trusts. This £12 million state‐of‐the‐art laboratory will contain the latest in automated analyser technology to deliver a high quality laboratory service to the populations of South of Tyne and Wear. Once commissioned, the building will be processing over 10,000 samples per day and will deliver the results back to the clinical desktop electronically. The service has been implementing a new Laboratory Information System which will go‐live on 30 September 2014, putting all three sites on a single IT system. Care Quality Commission ‐ In October the Care Quality Commission (CQC) issued the first of their “Intelligent Monitoring Reports” which gathers local and national data and assigns each NHS Trust a banding based on their risk to patients. Every Trust in the country has been graded from band 1 (highest risk) to band 6 (lowest risk) and our Trust was awarded a band 6 rating. This means that the CQC has recognised the QE as one of the safest places in the country for patient care. Cancer Care ‐ In 2013 the Trust was ranked by patients as the top performing hospital in the country for cancer care. Patients who participated in a survey on cancer patient experience rated the Trust on a wide range of measures including environment, staff, attitude, treatment and support. The Cancer Team will continue to improve and make a difference to the experience of patients dealing with cancer. The Gateshead Integrated Pathway for Adults with Diabetes ‐ This is an early exemplar model of what can be achieved through integrated working. A unified referral pathway and standardised documentation is being used by all practices to refer into this tiered service. It includes advice and guidance for GP’s, a specialist nursing helpline and multi‐disciplinary clinical assessment. Clear protocols are in place to identify when a patient can be managed within primary/secondary care and when care transfer is appropriate and/or possible. Education and support is central to the new model and an innovative education structure has been put in place, including a master class for GPs which has been extremely well received. Osteoporosis ‐ Our osteoporosis service has established strong links with Gateshead CCG and opportunities exist for developing a more community and primary care service to which the Trust will seek to make a significant contribution. Work is underway to develop pathway protocols allowing GPs to see more

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patients for osteoporosis screening supported by hospital consultants. A model is emerging, similar to diabetes care, where the complexity of patients’ need guides where they are seen within an integrated model, offering interventions from primary care detection through to hospital‐based care. Surgery ‐ The Orthopaedic Unit are now routinely treating patients with Dupuytrens contracture with Xiapex (collagenase) which is a new revolutionary non‐surgical treatment. They have achieved success in over 40 patients so far and avoided the need for surgery in all. 56 shoulder procedures under “awake” regional anaesthesia have now been performed and this is routine in the practice of Dr Jagannath Chakravarthy, Consultant Orthopaedic Surgeon. This avoids the need for general anaesthetic and is not done routinely nationally. The accelerated patient rehabilitation, reduces chances of inpatient stay, allows more complex patients to undergo surgery and has so far had a very high patient satisfaction outcome. Medicine ‐ The lung cancer multidisciplinary team have redesigned the initial pathway, so that patients referred by their GP can have a CT scan carried out on the same day if necessary, a process called ‘one‐stop’. Maternity ‐ In 2014 the Maternity Unit at the Trust began to offer an exciting new service providing 4D scans for pregnant women. This provides parents with the opportunity of finding out the sex of their baby from 16 weeks onwards and observing their baby’s movements with the added benefit of keepsake momentos of the experience. In 2013 the Trust’s Maternity Unit was given the highest, level three rating by the NHSLA (NHS Litigation Authority). This means that we are one of the safest places to come and have a baby in the country, offering the best level of care for mums and babies. Staff accolades have included: • The Woodside Unit and Ward 12 shortlisted for Nursing Times Awards; • Gynae‐oncology nursing team have published their work on supporting cancer patients via the

Foundation of Nursing Studies; • The Critical Care Department won a series of awards at the Northern Critical Care Network; and • Matron Janet Thompson won the poster award at her North East Leadership Academy (NELA)

leadership graduation day.

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Other Matters Equality and Diversity The Trust has adopted a human rights based approach to promoting equality, diversity and human rights. This is reflected in the ‘Vision for Gateshead’, which promotes the core values of equality, respect, trust, dignity and openness. The aim is to ensure services are accessible, culturally appropriate and equitably delivered to all parts of the community, by a workforce which is valued and respected, and whose diversity reflects the community it serves. To support accountability, there is a well established infrastructure in place which has provided leadership, governance and continuity, for example: • The Trust Board has appointed governors from diverse backgrounds, including Gateshead Youth

Council, the Jewish Council and the Diversity Forum for Gateshead. Many Governors are active members of groups and committees. Equality, diversity and human rights are promoted during the year at events, during training and development, and using the intranet on screensavers and through QE Weekly.

• The Equality and Diversity Steering Group undertakes a range of work, and membership includes

the Chairman, Deputy Chief Executive, Governors and Staff Side Representatives. The group ensures regular updates are provided to the HR Committee and provides assurance to the Trust Board on all aspects of equality and diversity, relating to both employment and healthcare services. Information about performance against equality objectives, equality analysis and the NHS Equality Delivery System are also published on a dedicated section of the Trust internet: http://www.qegateshead.nhs.uk/edhr

• The Disability Forum works with representatives from a wide range of local disability groups to

develop and implement the Integrated Disability Action Plan. The group is also supported by a dedicated disability awareness post.

• The Patient, Carer and Public Involvement Group continues to work with local people and key partner organisations, to ensure that they have a voice to influence the planning and delivery of health services.

• Work to promote equality, diversity and human rights has been undertaken by a wide range of

other groups throughout the Trust, including the HR Committee, Mental Health Committee, Patient Experience and Dignity Steering Group, Carers Group, Older People’s Champions network, Patient Information Group, Joint Consultative Committee and the five different strands of the Health and Wellbeing Strategy.

The Trust has published information about the four equality objectives, in accordance with the Equality Act (2010): • Leadership • Dignity and respect • Appropriate care • Being the best employer It has also developed and published an Equality Strategy 2013‐16. You can review the actions that we identified to help us to measure our progress towards our equality objectives by using the following link to our website: http://www.qegateshead.nhs.uk/sites/default/files/users/user1/Equality%20Objectives%20April%202012.pdf

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Equality Reporting and the Disclosure Requirements Gateshead Health NHS Foundation Trust is committed to providing the best possible quality of services and care for the people it serves. Being the best employer is one of the organisation’s key strategic themes and is central to our Vision and values of “Caring for you”. The Trust aims to promote equality and value diversity in employment practices, to ensure that prospective and existing members of staff are treated fairly and given equal opportunities to utilise their skills. Information about the Trust policies that help to underpin the aims is available on the Trust website, and the following policies were reviewed during 2013: • PP07 Employees Working in Other Organisations • PP09 Authorisation of Leave Policy • PP15 Employment Break • PP25 Mandatory Training Policy • PP27 Volunteers Policy • PP30 Induction Policy • PP33 Revalidation and Appraisal Policy for Senior Medical Staff • PP37 CONTACT Appraisal Policy • PP39 Well‐Being at Work Policy • PP43 Nursing and Midwifery Temporary Staff Bank Policy • PP44 Domestic Abuse Policy • PP45 Occupational Health Policy The Trust is also a Mindful Employer and a Disability Double tick symbol user. Communications The key theme over the past 12 months has been the Trust’s increasing emphasis on the use of social media to communicate with our stakeholders. The way organisations and the public are communicating is changing faster than ever before and at QE Gateshead we aim to be at the heart of these changes. We launched our new Facebook and Twitter sites in the summer of 2013 and have now really started to integrate them into our corporate communications work. The number of people who follow us on these channels is increasing rapidly and we are also able use social media to gather incredibly powerful intelligence from the public. Alongside this increasing focus on digital, we continue to work hard with the traditional media to generate positive coverage for our excellent services and answer questions from the press about our work. Over the past 12 months we have seen an increase in positive coverage for the Trust and there have been some real highlights in the local media. During this time the Trust has featured in the media 148 times, with the communications team issuing 29 press releases to promote good work. We have seen significant public interest in emergency care and one morning last December Gateshead hosted a live broadcast of the BBC Radio Newcastle Breakfast Show. We are particularly proud of our achievements in attaining the best possible risk rating from the Care Quality Commission (a band 6) where Gateshead received unprecedented praise and was given a clean bill of health for all of its services. The CQC were so impressed with the QE that they did not identify any recommendations for improvement for the hospital, which provides a key narrative for the QE story in the future.

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Our communications team is actively engaged in many projects and campaigns at any one time, all of which have a key impact on reputation and the Trust’s brand ‐ while also playing a vital part in ensuring that people choose the QE for their care. The coming year offers a range of exciting promotional opportunities primarily around the brand new Pathology Unit and our £32 million Emergency Care Centre, both of which are exciting stories for the people of Gateshead. Alongside this, we have seen an increase in the amount of patient feedback we receive through social media and websites such as NHS Choices. Where patients or their families raise concerns through NHS Choices we work hard to ensure prompt investigation and feedback is given. Last year saw the launch of a new patient feedback site called Care Connect and the Trust participated in the pilot for this system. The aim of this site is to provide a more responsive, live feedback service for patients. Throughout the year our communications team are supporting Trust staff to tell the positive stories about the QE – whether that’s keeping employees right up‐to‐date or delivering key messages to the public, it all plays a vital role in building a positive picture of excellent frontline care to patients and their families. Education, Learning and Development Investors in People Champion The Trust began work with Investors in People many years ago as a way to continuously develop and improve the organisation – seeing it as a way to support staff and ultimately to improve the quality and safety of patient care within the Trust. Investors in People (IiP) is an international award which recognises excellent people practices which directly contribute to a high performing organisation. Having achieved the gold standard in November 2012, which demonstrates that the organisation has reached the highest level of attainment, the organisation wished to share good practice with others. In August 2013, the Trust was successful in gaining Champion status. By becoming an IiP Champion, Gateshead Health NHS Foundation Trust is committed to sharing and also learning from experience, encouraging good practice across the region and supporting continuous improvement. Being an IiP Champion means: • Being a role model for other organisations who are aspiring to reach gold standard; • Sharing best practice, our experiences and lessons learnt; • Learning from other Champion organisations to understand different approaches and innovative

ways of working; • Assisting and encouraging others to use the standard as an organisational development (OD)

framework; and • Share how we have used the standard to improve the quality and safety of patient care. The Trust has already provided a number of organisations, including other trusts, with information, advice and guidance to support others to improve their own people practices. This is an excellent way of enhancing the reputation of the Trust and to ensure that we gain recognition for what we do well.

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Staff Health and Well‐being The Trust continues to recognise that a more satisfied and healthy workforce will be better able to engage in change and service improvement and provide a safer, high quality service to our patients and service users. The Trust underwent a rigorous assessment at the end of November 2013 to retain the Investors in People Good Practice Award for Health and Well‐being (HWB). We were the first hospital trust in the region to achieve this award three years ago and the report demonstrated the significant progress that had been made since that time. Detailed information on this and on our Staff Survey is given in the Quality Account on pages 160‐162. Developing our leaders The Trust has a long tradition of supporting leadership development and has this year approved a new Leadership Strategy which demonstrates the Central Team’s on‐going commitment to this important area. The purpose of this strategy is to ensure effective leadership within the Trust, necessary to sustain organisational health and excellence, in the context of a rapidly changing health environment. An Organisational Health Index (OHI) questionnaire, conducted in spring 2013, identified clear growth opportunities for leadership which will be addressed through the life of the strategy. Following a number of important reports such as Francis, Keogh and Berwick, we know that effective leadership means not only having the right knowledge and skills, but demonstrating the right behaviours and values to ensure patient safety and quality. Our strategy has embraced the NHS Leadership Framework as a means of ensuring that consistent messages are given around appropriate leadership behaviours. Working with Young People During the last year additional developments have been made in both the opportunities we provide within the Trust and the overall number of placements on offer. The introduction of a new Midwifery programme has meant that we have filled a much needed work experience gap for those hoping to pursue this particular career. After discussions with Medical staff the decision has also been made to expand the very popular Medical Shadowing programme by a further two weeks in the summer in order to provide valuable shadowing opportunities to those hoping to apply to study Medicine. Education Centre and Clinical Skills Centre Throughout 2013 the Trust has made good use of its investment into the refurbishment and modernisation of all of the teaching/meeting areas. The use of the SMOTs audio visual system has been in high demand within both simulation training and through more adventurous events linking our operating theatres and other clinical areas to lecture theatres, teaching rooms and even other hospitals in multi‐site training events. Weekend teaching activity has started to increase in frequency; clinical examinations for medical trainees and student led teaching sessions have both successfully been run on Saturdays and Sundays. Plans are also afoot to host a patient focus conference with delegate invitations open to the public. Evening medical student teaching activity has also shown an increase in popularity in recent months. Mock paces exams for medicine trainees was successfully hosted in the Clinical Skills Centre late during the year and proved so successful that future events are already booked to take place there.

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Future Workforce Nursing Cadetship Pilot – Seven Nurse Cadets commenced post in November 2012 as part of the trust’s future workforce strategy. The cadetship is an internally delivered programme that integrates both an Advanced Health Apprenticeship and BTEC National Extended Diploma in Health Studies. On completion of the programme the cadets are supported to apply to local universities to commence their BSc Adult Nursing in September 2014. Apprenticeships ‐ In total we have successfully delivered 29 apprenticeships within Health and Business Administration. Work Based Learning e‐Porfolio using iLearner ‐ As part of Work Based Learning’s drive to provide a quality learning journey we have implemented an e‐portfolio to support learners throughout vocational education. The iLearner system enables learners to access their portfolio’s instantly as well as live progress reports on their current development status. Staff Learning Zone ‐The Staff Learning Zone is the Work Based Learning vocational centre whereby all members of staff are able to access a member of Work Based Learning as well as use the resources. Personnel Policies and Procedures A programme of reviewing Personnel Policies and Procedures is jointly carried out with management and staff side representatives. Any developments in legislation, guidance and good practice are discussed and implemented as part of the review programme. The Trust has reviewed a number of its personnel policies and procedures over the year. These include: • PP07 Employees Working in Other Organisations (published April 2013) • PP09 Authorisation of Leave Policy (published August 2013) • PP15 Employment Break Policy (published April 2013) • PP27 Volunteers Policy (published April 2013) • PP33 Revalidation and Appraisal Policy for Senior Medical Staff (published June 2013) • PP43 Nursing and Midwifery Temporary Staff Bank Policy (January 2014) • PP44 Domestic Abuse Policy (August 2013) The following policies are currently under review: • PP10a Recruitment and Selection Policy (Non Medical Staff) • PP10a Recruitment and Selection of Consultants Policy • PP10c Appointment and Employment of Locum Medical Staff Policy • PP11 Managing Attendance Procedure • PP18 Flexible Working Policy • PP35 Raising Concerns Policy • PP40 Reference Policy • PP42 Work Attire and Appearance Policy Recruitment The Trust continues to review recruitment and selection practices with the aim of securing the best candidates for our vacancies, all within best practice, following employment legislation and NHS standards. In response to feedback from job applicants, we updated our recruitment information and the guidelines we provide to support people when they apply for our vacancies during 2013.

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As healthcare changes, what does not alter is the fundamental human need to be looked after with care, dignity, respect and compassion. During 2013 we introduced ‘values based recruitment’ processes into the recruitment of nurses and nursing assistants. This is based on the 6 C’s written in the Chief Nursing Officer’s ‘Compassion in Practice: Nursing, Midwifery and Care Staff, Our Vision and Strategy’. The aim is to enable recruiting managers to better identify the staff who have the compassion and commitment to deliver excellent patient, care, and the highest levels of safety and quality. During the past year the Personnel Department has continued to provide advice and support to staff involved in recruitment and selection procedures. We have continued to support trust‐wide recruitment for qualified nurses and nursing assistants. Pooling vacancies, inviting job applicants to recruitment events, and streamlining assessment and interview processes is more efficient. We advertise a much lower number of job adverts, but have a significantly improved attendance rate at job interviews. These arrangements work far better for individual job applicants also, as they do not receive numerous invitations for job interviews for very similar roles. The Personnel Department oversaw the introduction of new NHS guidance in relation to the six mandated NHS Employers Checks in July 2013, and they also rolled out the new NHS Jobs 2 system which went live in March 2014. The Trust is therefore in the process of updating our recruitment and selection policies to reflect these new arrangements. Assurance of compliance with NHS Employers Checks continues to be provided by departmental and internal audits. As a public sector organisation, we are statutorily required to uphold the public sector equality duty and ensure no one is treated less favourably when applying for a job. The Trust demonstrates a commitment to being a “positive about disabilities” employer through the use of the two tick symbol and Mindful Employer pledge. Developing an integrated approach to the recruitment, appraisal and revalidation of the medical workforce has been a Trust‐wide priority, and we have of a dedicated Revalidation/Clinical Governance Support Officer. Employee Statistics Staff Groups Female Male Directors (to include Chair and Non‐Executive Directors) 5 9

Senior Managers (Associate Directors) 3 1

Employees 2864 704 Sickness Absence Managers across the Trust have worked hard to manage sickness absence throughout 2013/14. The overall absence figure for the period is 4.97%, which compares reasonably when benchmarked with other local Foundation Trusts. As always, the winter months were especially difficult, particularly for clinical areas, as the traditional colds/flu and winter viruses were once again evident. Over the year the most prevalent reasons for absence mirror the previous 12 months, and in the case of ‘stress’ and ‘musculoskeletal injuries’ are consistent with the national public sector position. Occupational Health continues to work with the Trust’s Physiotherapy service to provide a ‘fast‐track’ referral service for staff. This work, although difficult to evaluate is beginning to have a positive impact on length of absences.

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Last year the Trust began rolling out a programme of Resilience Training designed to help staff cope with the pressures of work/life and manage these appropriately. In addition, external counselling support has been accessed and as a result the waiting list for this service has been significantly reduced. One to one support is offered through Occupational Health and a number of physical exercise activities are available across the Trust to encourage healthy lifestyles e.g. zumba, netball and health walks. The Personnel Team offers continuous assistance to managers in dealing with both long and short term sickness to ensure members of staff are supported throughout their absence and are able to return to their usual work, or a temporarily adjusted situation, as soon as possible. The Occupational Health and Personnel Departments provided mandatory training for managers in managing and supporting employees with mental health conditions, in addition to the revised training in managing attendance at work. The Trust has now committed targeted resources to help reduce sickness within the Trust by employing dedicated staff within the Personnel, Occupational Health and Physiotherapy Departments who will solely be helping increase attendance at work and help target areas of concern. Regular attendance management updates and audits continue to be presented to the HR Committee to ensure they are able to monitor progress and identify appropriate areas for further work and development. Furthermore, in order to help the Trust monitor performance in managing absence, data is routinely obtained from the Electronic Staff Record Data Warehouse which allows us to benchmark our data against other local Trusts. The most recent audit of attendance management was carried out in December 2013. The action plan identified as a result of this audit has been fully implemented. Activities mainly related to the updating of the Trust policy for Managing Attendance and the revision of the Return to Work pro‐forma to support managers in this area. The policy is being revised in conjunction with Staff Side colleagues during Spring/Summer 2014. Countering Fraud and Corruption We take our responsibilities to protect our resources from fraud, bribery and corruption (fraud) seriously. Our aim is to reduce fraud to an absolute minimum and keep it there, permanently. We are committed to compliance with the Bribery Act 2010 and to promoting and maintaining an absolute standard of honesty and integrity in conducting our business. We continue to prevent fraud from occurring by using best practice in fraud‐proofing high risk systems and policies. Where we cannot prevent fraud we ensure it is detected quickly. We participate in the National Fraud Initiative, led by the Audit Commission, and also undertake proactive local exercises to detect fraud. Our professionally trained local counter fraud specialist rigorously investigates all allegations of fraud; reporting each investigation to the Audit Committee and applying appropriate criminal, disciplinary or other sanctions as appropriate. We participate in the NHS Protect quality assurance process who evaluates our anti‐crime arrangements as effective. Sustainability/Climate Change Throughout 2013/14 the Trust has again been proactive with its Carbon Reduction and Sustainability programme to form an integral part of delivering high quality healthcare efficiently. The Trust’s continuing voluntary commitment to the European Union Emissions Trading Scheme (EU ETS), its inclusion in the Carbon Reduction Commitment program (CRC) and continued participation in the Salix Fund (carbon reduction program) are fundamental elements in our approach to reduce carbon and drive efficiencies. They also provide vehicles to track progress in meeting the NHS’ commitment to a 10%

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reduction by 2015 and the mandatory governmental targets for emission reductions of 34% by 2020 and 80% by 2050. With energy costs reaching record highs it is vitally important to focus our efforts on reducing consumption and minimizing waste This year we have seen definite benefits of the schemes carried out during 2013 which continue to generate revenue savings, through greater efficiencies: • Installed energy efficient LED lighting with lighting controls • Evaporative cooling to server rooms • Expanded the Trust BMS System incorporating Zone controls • Car park lighting upgrades to LED • Upgrades to condensate recovery systems These schemes have helped not only to reduce energy consumption but also continue our commitment to reduce carbon. Utility and Waste Management Performance

Activity Quantity 2012/2013

Quantity 2013/2014 Costs

2012/2013 Costs 2013/14

Waste Management

Total Waste produced by the Trust

1,032 Tonnes 1,093 Tonnes Expenditure £324,398 £338,043

Utilities

Gas 22,934,230 Kwh 21,300,530 Kwh Gas £833,228 £822,767

Oil 0 Kwh 0 Kwh Oil £0 £0

Electricity 9,625,267Kwh 10,071,490 Kwh Electricity £937,044 £1,190,744

Water 109,141 M3 122,504 M3 Water £292,712 £332,315

We are now into the seventh year of our Energy Strategy, and despite record fuel prices, Energy and water used in construction of the New Emergency Care Centre and the South of Tyne Pathology Laboratories aligned with increased activity during 2013/14 the table above illustrates a creditable performance. The Future The introduction of the CRC scheme has added additional pressures of £101,244 to the energy budget this year, the full impact of this scheme in year 2014/2015 will increase the pressure further to £200,000. The Trust has put a greater focus on energy efficiency and sustainability and is committed to continuing investment to improve energy efficiency and sustainable developments. With two new developments due for completion, the ECC (Emergency Care Centre) Autumn 2014 and the South of Tyne Pathology Laboratories Spring 2014, the Trust is committed to building in a Sustainable and Energy Efficient way and aims to achieve a BREEAM ‘Excellent’ and BREEAM ‘Very good ’ rating respectively. Continued investment in new technologies and improved use of existing plant, combined with continued monitoring of energy inefficiencies and consumption plus lifecycle costing will ensure compliance with Government, EU ETS and CRC targets.

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Directors’ Report

Public Interest Disclosures Involvement and Consultation The Trust has made a commitment in its Vision to place patients at the heart of everything that we do. Understanding the needs, wants and experiences of our patients is integral in the NHS today as well as within our Trust. This understanding is important at every level, from the specific decisions we make with patients about their personalised programme of care, to the decisions about when, where, how and by whom services are provided. In 2013 the Francis Inquiry Report into the failings at Mid Staffordshire NHS Foundation Trust was published, and fundamental to its 290 recommendations is placing patients at the core of the NHS. At around the same time a number of other reports and reviews were published into other problems with health and social care in various settings around the country. The outcome of these reviews all support the strengthening of patient and public involvement throughout the NHS. The Trust therefore has a very active programme of work to gain essential feedback from our patients and the public about the care they, and their loved ones, receive, and to engage patients, the public, communities and stakeholders in service planning and development. However, we have previously had two distinct, though overlapping, strands to our work in this area: a patient experience and dignity strand and a patient involvement and engagement strand. Each of these workstreams has worked well to gain the engagement and feedback we need to understand how our services do and to help us improve quality by delivering what our patients want in the way they want it. In the current context however, in 2013 and the early part of 2014 we reviewed the way in which we organise this work and we start this financial year with a new and refreshed Patient Involvement and Experience Strategy. The heart of this Strategy, ‘5 Steps to Excellent Care’ is a framework we have built based on the specific things our patients told us they wanted to see in their care. We look forward to building on our excellent foundations with this new, re‐energised approach, and working with our patients and community to make exciting changes and improvements in our services. Another key change this year has been the formation of Healthwatch Gateshead, and we have established good and open relationships with them over the past year. We look forward to a really positive working relationship with Healthwatch into the future and value their feedback on the work we are doing. Throughout 2013/14, we continued to work with a whole range of patients, partners and stakeholders on many issues. Some highlights include: • Working with children and young people and the Gateshead Youth Council, in the design of the

children’s areas in the new Emergency Care Centre. • Working with patients on new patient picture menu booklets which show the menu choices for the

day in a clear, simple and visual way. • In 2013/14 a plan was agreed by Governors to increase their engagement with Members through

local community events. This gives members a greater opportunity to feed‐back their views to the Trust on new or revised services.

• Members continue to receive a joint members and staff newsletter, QE News which is published three times a year and sent to members via email or post.

• Our Medicine for Members programme of seminars continues to be very successful and five of these events were held during 2013/14. Topics included Stroke, Organ Donation, Hip Replacements, Thyroid Disease and Lung Disease.

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• Involving patients in the PLACE inspections on our wards and in our departments. These inspections look at the environment to ensure it is clean, safe and fit for purpose

• Involving patients in our successful 15 Steps Challenge programme, which helps us to improve things in clinical areas based on the 1st impressions of patients.

• We have continued to implement the Friends and Families test, as set out in national guidance, and use the information from this for quality improvement

• We asked patients to help us improve the design of our post natal ward. We now have great new facilities which meet the needs of the women and their partners.

• We ensure we attend meetings and events run by our partners such as the Clinical Commissioning Group and the Local Authority as well as those in the voluntary and charitable sector.

Of course, involving patients, carers and their families is something our staff do every day in the wards and departments so this section has just provided a snapshot of some of the ways in which we bring this work together to make a difference for our patients. Much more detail can be read in our Quality Account. Serious Incidents Involving Personal Data

Summary of Serious Incident Requiring Investigations Involving Personal Data as Reported To The Information Commissioner’s Office in 2013/14

Date of incident (month)

Nature of incident Nature of data involved

Number of data subjects potentially affected

Notification steps

July 2013 Encrypted electronic NHS Patient data disclosed in error

Personal and detailed clinical information 59 Individuals not

notified

Further action on information risk

A review of all GP Practice email addresses held on IT Systems will be undertaken along with current verification and validation processes. Formal change control procedures will be introduced for system updates/changes, ensuring full testing is carried out in controlled environments. Appropriate training will be provided to relevant staff. No disciplinary action was taken for this incident.

Date of incident (month)

Nature of incident Nature of data involved

Number of data subjects potentially affected

Notification steps

October 2013 Paper documentation disclosed in error

Name, Address, DOB and NHS Numbers 181 Individuals not

notified

Further action on information risk

A review of processes will be undertaken to ensure the service provided is safe, effective and cost efficient. A formal process of change notification, testing and sign off prior to template changes will be introduced. Robust lines of communication will be embedded within teams. No disciplinary action was taken for this incident.

Gateshead Health NHS Foundation Trust will continue to monitor and assess its information risks, in light of the events noted above, in order to identify and address any weaknesses and ensure continuous improvement of its systems.

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Governance Report Board of Directors The Board’s key responsibilities are: • To set strategic objectives, taking into account views of the Council of Governors and other key

stakeholders; • To provide the healthcare required under its contracts with commissioners and other

organisations; • To ensure appropriate governance and performance arrangements are in place to deliver the

Trust’s strategic objectives; • To ensure the quality and safety of all healthcare services, research and development, education

and training; and • To ensure that the Trust complies with the terms of its standard licence conditions. Our standard licence conditions and constitution govern the operation of the Trust. The Schedule of Reservation and Delegation of Authority sets out the types of decisions that must be taken by the Board of Directors and those which can be delegated to management. The constitution defines which decisions must be taken by the Council of Governors and how disagreements between the Board and the Council of Governors should be resolved. Composition of the Board The Board currently has eight Non‐Executive Directors (including the Chairman) and six Executive Directors (including the Chief Executive). The appointment of the Chairman and appointment/reappointment of Non‐Executive Directors is approved by the Council of Governors. The appointment of the Chief Executive is by the Non‐Executive Directors, subject to ratification by the Council of Governors. Balance of Board Membership and Independence The Board has complied with the requirements of the constitution in relation to Board composition. The Board is satisfied that it has acted appropriately, has been balanced, complete and has contained a suitable range of appropriate and complementary skills and experience. The Board considers that all the Non‐Executive Directors are independent and Mr Frank Major is the named Senior Independent Director. He also leads the appraisal process of the Chairman. Disclosure to Auditors The Directors of the Board at the time the annual report is approved can confirm that: • So far as they are aware, there is no relevant audit information of which the NHS foundation Trust’s

auditor is unaware; and • They have taken all 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 Foundation Trust’s auditor is aware of that information

Performance Evaluation The Trust has a process in place for performance evaluation of Non‐Executive Directors and the Chairman that complements existing arrangements for executive directors. The process includes one to one appraisal

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and collective development of an action plan for board performance as a whole. The results of these appraisals are reported to the Council of Governors. Access to register of Directors’ Interests The members of the Board declare their interests annually at a public meeting. These are recorded in a register of Board members’ interests, available for inspection by the public on request. Members of the public can gain access to the register of Directors’ interests by making a request to the Trust Secretary, Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Sheriff Hill, Gateshead. NE9 6SX, or via email [email protected] Board meetings and committees The Board supports the Nolan principles and makes the majority of its decisions in meetings open to the public. The Board met in public 8 times during the year. It also met in private 11 times and held 4 informal away days during the year. The board delegates some of its work to committees. There is a standing item at each board meeting to receive the minutes of the board committee meetings. Directors’ Attendance at Board Meetings 2013/14 Non Executive Directors AttendanceMrs JEA Hickey (Chairman) 11/11Mr S Bowron (from 1 July 2013 ) 7/7Mr M Brown 7/11Dr J Bryson 10/11Dr A Fairbairn 6/11Mr M Graham (to 30 June 2013) 3/4Mr M Henry (from 1 July 2013) 5/7Mrs K Larkin‐Bramley 11/11Mr F Major 9/11Mr R Simpson (until 30 June 2013) 3/4Executive Directors AttendanceMr J Connolly 10/11Mr K Godfrey 10/11Mr P Harding 9/11Mrs G MacArthur 8/11Mrs Y Ormston 10/11Mr I D Renwick (Chief Executive) 9/11Associate Directors AttendanceMr S Atkinson 11/11Mrs C Coyne 8/11Mrs C Hesketh 7/11Mrs S Pearson 8/8

Related Party Transactions Gateshead Health NHS Foundation Trust is required under IAS 24 to disclose material transactions undertaken with a related party. See Notes 16.4 – 16.6 on page 245‐246 of the accounts.

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During the year none of the Board Members or members of the key management staff or parties related to them, has undertaken any material transactions with Gateshead Health NHS Foundation Trust. The Foundation Trust has received revenue and capital payments from the Gateshead Health NHS Foundation Trust Charitable Fund. All of the Trustees of the charity are members of the Board of Directors. Board Members Chairman Julia Hickey Julia is a chartered accountant and was appointed as Chairman on 1st July 2012 having previously been a Non‐Executive Director of the Trust. She has also held non‐executive posts in housing and education and is currently a Board Member of Northumbria Probation Trust. Julia’s term of office ends on 30 June 2015. Chief Executive Ian Renwick Ian was appointed as the Trust’s Chief Executive in August 2006, having previously been the Director of Finance and Information at the Trust since 2001. He is a qualified CIPFA accountant and has worked in the NHS in the north east since 1996. Ian is the Chair of the North East Transformation System, and is also a Governor at Gateshead College. Non‐Executive Directors Shaun Bowron Shaun has a background in media spanning 35 years in both the regional press and commercial radio. Prior to joining the board in July 2013, he was Group Operations Director with GMG Radio, part of the Guardian Media Group. His previous roles include Managing Director and Brand Managing Director. He has commercial, marketing and general management skills having worked at board level for over 20 years. Shaun’s term of office ends on 30 June 2016. Kathryn Larkin‐Bramley Kathryn is a fellow of the Institute of Chartered Accountants in England and Wales and has served as an NHS Non‐Executive Director in the North of England for ten years. Kathryn’s term of office ends on 30 June 2015. Mitch Brown Mitch is a commercial lawyer based in the north east but working throughout the country on public sector projects for a national law firm. He took up post on 1 June 2005. His period of office ends on 30 June 2015. Joan Bryson Joan has been a GP in Low Fell since 1988. She was a GP member of the PCG for many years. Joan was appointed on 1st July 2011 and her current term of office ends on 30 June 2017. Andrew Fairbairn Andrew retired as a Consultant Old Age Psychiatrist with Northumberland, Tyne and Wear NHS Trust (NTW) in November 2008. He had also been the Medical Director of NTW and two predecessor organisations and had two spells as Acting Chief Executive. He chaired the group that created the NICE Guidelines on Dementia in 2007 and has been a Policy Adviser to the Department of Health. Andrew was appointed on 28 May 2009 and his term of office ends on 30 June 2015.

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Malcolm Graham Malcolm is a local Labour councillor in Gateshead. He was a Non‐Executive Director of the former Gateshead Healthcare NHS Trust. His term of office ended on 30 June 2013. Mick Henry Mick was first elected as a councillor for the inner city ward of Saltwell in 1986 and has been Leader of the Council since 2002. In 2007, he was awarded a CBE for his services to local government. He is also involved in a number of major national bodies, including the Local Government Association's General Assembly and its Rural and Urban Commissions. Before becoming a councillor, he was a Senior Lecturer in Photography and Head of Digital Imaging and Northumbria University and he previously held posts in most sectors of education, included class teacher in a special school. He also worked in industry and the NHS, in the field of efficiency improvement/management services. Mick was appointed in June 2013 and his term of office ends on 30 June 2016. Frank Major MBE Until his retirement in 2005, Frank enjoyed a professional career in International maritime transport and logistics. He is Chairman of the Three Rivers Local Nature Partnership and is also actively involved in the leadership of several voluntary organisations. He was appointed a Deputy Lieutenant for Tyne and Wear in 2007. He became a Non‐Executive Director on 5 January 2006. He was appointed Vice Chairman and Senior Independent Director in February 2007. Frank’s term of office ends on 30 June 2014. Richard Simpson Richard has a background in media and public relations. He now runs his own business specialising in coaching, mentoring and human behaviour consultancy. He is also a director of Age Inclusive Ltd which helps employers develop positive solutions to issues relating to age in the workplace. He was appointed as Non‐Executive Director from 5 January 2006 and his term of office ended on 30 June 2013. Executive Directors Jon Connolly ‐ Director of Finance and Information Jon joined the Trust in April 2012. He has worked in the NHS since 2007, holding a number of senior finance roles, including Acting Director of Finance at South Tees Hospitals NHS Foundation Trust. Before joining the NHS Jon worked for the Audit Commission. Keith Godfrey ‐ Medical Director Keith was appointed as Medical Director in February 2013. He has worked as a specialist in Gynaecological cancers at the Trust for the last twelve years. Peter Harding ‐ Director of Estates and Facilities Peter was appointed as Director of Estates in 1990. Peter is a Chartered Surveyor who has worked in Gateshead since 1982. In 2014 Peter also became a Non‐Executive Director for Four Housing Group a Registered Provider of Social Housing. Gillian MacArthur ‐ Director of Nursing and Midwifery and Quality Gillian was appointed Director of Nursing and Midwifery in July 2010 and has worked in the NHS for 24 years. She has experience in both clinical and senior management roles. She was previously Deputy Director of Nursing and Midwifery at Gateshead Health NHS Foundation Trust.

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Yvonne Ormston ‐ Deputy Chief Executive/Director of Transformation and Compliance Yvonne was appointed in April 2005. She is an experienced manager who has worked in the NHS for 26 years. Her most recent appointment was locality Director at Northumberland Care Trust. She was previously Chief Executive of Gateshead PCG. She was appointed Deputy Chief Executive in January 2012. Committees Audit Committee: During the year the Audit Committee considered the significant issues in relation to financial statements, operations and compliance. The draft financial statements for 2013/2014 were discussed and reviewed at its May meeting and, in particular, issues regarding valuation and provisions were discussed and agreed as follows: Revaluation of land and buildings ‐ A full revaluation of the Trust’s land and buildings was undertaken during the 2013/14 financial year by a professionally qualified valuer. This revaluation has been reflected in the financial statements. The Audit Committee considered and accepted the basis of this valuation and its disclosure in the financial statements. Provisions ‐ The Trust has a number of provisions included in the financial statements. The Audit Committee considered the judgements and methodology used by management in assessing these provisions together with the presentation and disclosure aspects included in the financial statements. The Audit Committee also reviewed the Annual Governance Statement taking assurance from Internal Audit Reports, the work of the PQRS Committee, the Finance Committee and updates to the Board Assurance Framework. The Committee have not been made aware of any concerns around governance or breaches of internal control during the year, which would need to be reflected in the Annual Governance Statement. All reports in which Internal Audit reported that they had gained ‘limited assurance’ from their review were considered specifically by the Audit Committee. As a result of these specific reviews, the Committee were able to satisfy themselves that none of the concerns raised were significant in the context of the Annual Governance Statement and its other responsibilities. External audit provided their External Audit Plan to the Audit Committee in December. This outlined key audit risk areas. External Audit reported back on these risk areas in their ISA 260 and in particular commented on the risk associated with the revaluation of property and recognition of income and provisions. Members of the Committee take the opportunity to have a discussion with the auditors following the Committee meetings without any officer of the Trust being present. The purpose of these discussions is to ensure that there were no matters of concern arising from external audit regarding the running of the organisation that should be raised with the Audit Committee. Any matters discussed at these meetings are reported to the Board of Directors. The Committee also reviewed its self‐assessment completed in September 2013 and terms of reference to ensure they enable continued robust challenge and adherence to the Committee’s purpose. This is the second year KPMG LLP have acted as external auditors to the Trust. They were appointed following a competitive tendering exercise in April and May 2012, for a contract period of three years until July 2015. The fee to External Audit for work undertaken under the Audit Code included the opinion on the financial statements, the review of the Annual Governance Statement, the opinion on the economy, efficiency and effectiveness of the Trust, work to support the Whole of Government Accounts and the review of the Quality Report and Charity audit. The value of this work was £45,405 during 2013/14.

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KPMG also provided non‐audit services during the year. In particular, KPMG have provided services with regard to VAT and Pension Services, with a total value of £39,000. Neither of these pieces of work were contingent on any outcome and the audit teams involved were separate to those engaged during the audit of the financial statements. Therefore, we consider that appropriate safeguards are in place to ensure continued audit objectivity. There were 5 audit committee meetings in 2013/14 Member Attendance at MeetingsChairman Mrs K Larkin‐Bramley 5/5Mr M Brown 2/5Dr A Fairbairn 3/5Mr F Major 4/5

Finance Committee: The Finance Committee is a formal committee of the Board with delegated responsibility to monitor, review and make recommendations to the Trust Board, if necessary, with regard to the detailed financial performance of the Trust. There were 12 meetings of the Committee in 2013/14. Member Attendance at MeetingsChairman Mrs JEA Hickey 12/12Mr J Connolly 10/12Mrs K Larkin‐Bramley 11/12Mr F Major 10/12Mrs S Pearson 12/12Mr ID Renwick 9/12

Nominations and Remuneration Committee: The purpose of the Nominations and Remuneration Committee is to review the structure, size and composition of the Board of Directors and make recommendations for changes where appropriate. It also sets the remuneration and Terms and Conditions of employment of the Executive Directors. The Committee comprises the Chairman and all Non‐Executive directors of the Board. The Committee met once in 2013/14. Member Attendance at MeetingsChairman Mrs JEA Hickey 1/1Mr S Bowron 1/1Mr M Brown 1/1Dr J Bryson 1/1Dr A Fairbairn 0/1Mr M Henry 0/1Mrs K Larkin Bramley 1/1Mr F Major 0/1

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Remuneration Report This report provides information on the remuneration, terms of service and the frameworks for performance and evaluation of both Executive and Non‐Executive Directors. Executive directors: The Board has an established Nominations and Remuneration Committee; its membership comprises the Chairman (who chairs the Committee) and all Non‐Executive Directors. The purpose of the Committee is to determine and keep under review the pay and terms of service of Executive Directors. The Chief Executive and Head of Personnel provide advice and support to the Committee but the Chief Executive is excluded from any discussions and decisions which affect his own pay. The Nominations and Remuneration Committee met one time during 2013/14. An annual salary review is undertaken to determine whether an annual uplift should be awarded and if so the level of the uplift. In making this decision the Committee takes into consideration a number of factors including the level of pay awards made nationally to other staff groups within the NHS as well as Department of Health guidance and the affordability to the organisation. The Committee is authorised to appoint external consultants and advisers and uses this route to undertake regular benchmarking exercises. Performance evaluation of Executive Directors is undertaken by the Chief Executive. The Chairman is responsible for evaluation of the performance of the Chief Executive. No element of remuneration is subject to performance conditions. This process will continue in 2014/15. The Chief Executive, and other Executive Directors (except the Medical Director) were all appointed through an external recruitment interview process. The Medical Director is a permanent member of the consultant medical staff, appointed as executive medical representative by the Board. The current Medical Director was appointed in February 2013. All posts are permanent and may be terminated by mutual agreement, resignation or dismissal. The notice period for Executive Directors is three months. There has been no provision for compensation for early termination or significant awards made to past executive senior managers in the last 12 months. The Trust currently has no provision for compensation for early retirement. Chairman and Non‐Executive Directors: The Trust has an established Remuneration Committee of the Council of Governors to review and make recommendations on levels of remuneration for the Chairman and Non‐Executive Directors. In 2013/14 the members of the Council of Governors Remuneration Committee were: Mr R Thorold – Appointed Governor (Chair) Mr S Dae – Staff Governor Mrs S Gallagher – Elected Governor (from March 2014) Mr J Holmes – Elected Governor (until December 2013) Mr P Hopkinson – Elected Governor Mr I Stafford – Staff Governor Mr P Tinnion – Elected Governor (until December 2013) Professor T Waring – Elected Governor (from March 2014) Individual performance appraisal of Non‐Executive Directors is undertaken by the Chairman. Performance appraisal of the Chairman is undertaken by the Vice Chair (who is also the Senior Independent Director).

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Evaluation of the performance of the Board as a whole, as well as the Chairman and Non‐Executive Directors as individuals, is undertaken in accordance with a framework approved by the Council of Governors. No element of remuneration is subject to performance conditions. The Chairman and Non‐Executive Directors were appointed by the Council of Governors in accordance with the constitution of Gateshead Health NHS Foundation Trust, for the terms of office indicated on pages 43‐45. The removal of the Chairman or Non‐Executive Directors requires the approval of three‐quarters of the Council of Governors. In September 2013 the Governors’ Remuneration Committee met to discuss continuity and succession planning of the Non‐Executive Directors. Following the terms of office of one NED coming to an end in 2014, the Governors agreed that the post would go to external advert. This decision was ratified by the Council of Governors in November 2013. There has been no provision for compensation for early termination or significant awards made to past Non‐Executive senior managers. Remuneration: Remuneration for Directors and other senior employees is included in the following table:

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2012/13

Name and Title

2013/14 Salary

Other Remuneration

Benefits in Kind

Pension‐related Benefits Total Salary Other

Remuneration Benefits in

Kind Pension‐related

Benefits Total

(bands of £5000) £000

(bands of £5000) £000

Rounded to the nearest £100

(bands of £2500) £000

(bands of £5000) £000

(bands of £5000) £000

(bands of £5000) £000

Rounded to the nearest

£100 (bands of

£2500) £000

(bands of £5000) £000

10 ‐15 0 300 0 10 ‐15 Mr PJ Smith Chairman (to 30 Jun 2012) N/A N/A N/A N/A N/A 30 ‐35 0 0 0 30 ‐35 Mrs JEA Hickey Chairman (from 1 Jul 2012) 45 ‐50 0 0 0 45 ‐50

205 ‐210 0 12,700 107.5 ‐110.0 330 ‐335 Mr ID Renwick Chief Executive 210 ‐215 0 8,000 32.5 ‐35.0 255 ‐260

130 ‐135 0 8,800 42.5 ‐45.0 180 ‐185 Mrs YA Ormston Director of Transformation & Compliance and Deputy Chief Executive 130 ‐135 0 9,700 27.5 ‐30.0 170 ‐175

120 ‐125 0 4,400 97.5 ‐100.0 220 ‐225 Mrs G MacArthur Director of Nursing, Midwifery & Quality 120 ‐125 0 5,500 35.0 ‐37.5 160 ‐165

55 ‐60 135 ‐140 * 0 (30.0) ‐(27.5) 160 ‐165 Dr DM Beaumont Medical Director (to 31 Jan N/A N/A N/A N/A N/A

10 ‐15 0 0 0 10 ‐15 Mrs T Preece Acting Director of Finance & Information (to 29 Apr 2012) N/A N/A N/A N/A N/A

115 ‐120 0 600 237.5 ‐240.0 355 ‐360 Mr JM Connolly Director of Finance & Information (from 30 Apr 2012) 130 ‐135 0 8,100 37.5 ‐40.0 180 ‐185

135 ‐140 0 1,800 37.5 ‐40.0 175 ‐180 Mr P Harding Director of Estates & Facilities 135 ‐140 0 7,800 (52.5) ‐(50.0) 90 ‐95

N/A N/A N/A N/A N/A Mr S Bowron Non Executive Director (from 1 Jul 2013) 10 ‐15 0 0 0 10 ‐15

10 ‐15 0 0 0 10 ‐15 Mr MJ Brown Non Executive Director 10 ‐15 0 0 0 10 ‐15 10 ‐15 0 0 0 10 ‐15 Dr JM Bryson Non Executive Director 10 ‐15 0 0 0 10 ‐15 10 ‐15 0 0 0 10 ‐15 Dr AF Fairbairn Non Executive Director 10 ‐15 0 0 0 10 ‐15

10 ‐15 0 0 0 10 ‐15 Mr MW Graham Non Executive Director (to 30 Jun 2013) 0 ‐5 0 0 0 0 ‐5

N/A N/A N/A N/A N/A Mr MF Henry Non Executive Director (from 1 Jul 2013) 10 ‐15 0 0 0 10 ‐15

0 ‐5 0 0 0 0 ‐5 Mrs JEA Hickey Non Executive Director (to 30 Jun 2012) N/A N/A N/A N/A N/A

5 ‐10 0 0 0 5 ‐10 Ms KA Larkin‐Bramley Non Executive Director (from 1 Oct 2012) 15 ‐20 0 0 0 15 ‐20

15 ‐20 0 0 0 15 ‐20 Mr FG Major Non Executive Director 15 ‐20 0 0 0 15 ‐20

10 ‐15 0 0 0 10 ‐15 Mr RE Simpson Non Executive Director (to 30 Jun 2013) 0 ‐5 0 0 0 0 ‐5

45 ‐50 0 0 0 45 ‐50 Mrs D Atkinson Trust Secretary 45 ‐50 0 0 0 45 ‐50

25 ‐30 125 ‐130 * 0 (65.0) ‐(62.5) 85 ‐90 Mr K Godfrey Medical Director (Full Medical Director from 1 Feb 2013) 65 ‐70 115 ‐120 * 0

(1,607.5) ‐(1,605.0)

(1,425) ‐(1,420)

NB all senior managers are continuing except where stated. * Other remuneration refers to that as a consultant. ** Ian Renwick left the NHS Pension Scheme on 1st January 2014. In lieu of employer's contributions to the scheme he received a payment of £7,335 during 2013/14. This is the sum that the Trust would have contributed Benefits in Kind relate to lease car payments made by the Trust. No other remuneration or pensions contributions are paid to/for these senior managers. There were no golden hellos or compensation for loss of office.

Director/Governor Expenses During 2013/14 the Trust had 37 governors, 5 of whom claimed expenses totalling £121. The Trust had 16 Directors (Executive and Non‐Executive), 7 of whom claimed expenses totalling £4,216. In comparison during 2012/13 the Trust had 35 governors, 2 of whom claimed expenses totalling £51.50 and 16 Directors (Executive and Non‐Executive), 9 of whom claimed expenses totalling £5,257. These claims were in accordance with the Trust’s Travel and Subsistence Policy. Full details of Directors’ and other senior employees’ remuneration are shown on page 229 of the accounts. Accounting policies for pensions and retirement benefits are shown on page 214‐215 of the accounts. Signed: Date: 21 May 2014 Mr I D Renwick, Chief Executive

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Council of Governors The Council of Governors includes 16 public governors and one patient governor elected by members of the Foundation Trust. It also has six staff governors elected by hospital staff. They are joined by nine nominated representatives from our partner organisations. Our Governors play an important role in helping us communicate with our members and partner organisations about our vision, performance and strategy. It is their responsibility to maintain and review the Membership strategy and increase our membership. They also have specific responsibilities in regards to the appointment and remuneration of our Chairman and Non‐Executive Directors, the appointment of the external auditor and the holding to account of Non‐Executive Directors individually and collectively for the performance of the Board of Directors. The Board of Directors consults with them at a joint workshop when the operational plan is being prepared and at a mid‐year review. Governors receive regular reports at meetings on financial/clinical performance and quality. Governors are also consulted on other issues such as revisions to our constitution. The Board of Directors also attend the meetings of the Council of Governors and members of the Council of Governors attend as observers at the Board of Directors’ meetings. Papers and agendas for both meetings are shared. The Trust Chairman chairs both the Board and the Council of Governors and acts as a link between the two. A Non‐Executive Director is a member of the Membership Strategy Group and as members of the Trust, Non‐Executive Directors receive all information sent to members. The relationship between the Council of Governors and the Board of Directors is key and the Trust continues to build upon opportunities for shared activities. During 2013/14 the Council of Governors met in public four times. Agenda, papers and dates of meetings can be found on the website (details of which are on the back cover). In addition to attendance at formal Council of Governor meetings, Governors have also met as part of working groups and committees throughout the same period. Each Governor’s attendance at the Council of Governors is shown in the constituency list on page 52 and 53. Attendance by the Board of Directors was:

Name Position Meetings Attended

Shaun Bowron Non‐Executive Director (from 1 July 2013) 3 out of 3

Joan Bryson Non‐Executive Director 4 out of 4

Mitch Brown Non‐Executive Director 0 out of 4

Jon Connolly Director of Finance and Information 3 out of 4

Andrew Fairbairn Non‐Executive Director 3 out of 4

Keith Godfrey Medical Director 3 out of 4

Malcolm Graham Non‐Executive Director (to 30 June 2013) 0 out of 1

Peter Harding Director of Estates and Facilities 3 out of 4

Mick Henry Non‐Executive Director (from 1 July 2013) 2 out of 3

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Name Position Meetings Attended

Julia Hickey Chairman 4 out of 4

Kathryn Larkin‐Bramley Non‐Executive Director 4 out of 4

Gillian MacArthur Director of Nursing, Midwifery and Quality 3 out of 4

Frank Major Vice Chairman and Senior Independent Director 3 out of 4

Yvonne Ormston Deputy Chief Executive 4 out of 4

Ian Renwick Chief Executive 4 out of 4

Richard Simpson Non‐Executive Director (to 30 June 2013) 0 out of 1

Council of Governors

Public Governors Constituency Appointment Meetings Attended

Eileen Adams Central 3 years from 2014 1 out of 1

Ann Atkinson*** Central 3 years from 2011 3 out of 3

John Bolam Central 3 years from 2014 1 out of 1

Audrey Clark*** Central 3 years from 2011 2 out of 3

Anna Ellinson Central 3 years from 2012 2 out of 4

Sheila Gallagher Central 3 years from 2014 1 out of 1

Jim Holmes**** Central 3 years from 2013 3 out of 3

Gillian Huthart Central 3 years from 2012 4 out of 4

Francis Kanu Central 3 years from 2013 4 out of 4

Mary Richards* Central 3 years from 2011 2 out of 3

Teresa Waring Central 3 years from 2014 1 out of 1

Tom Bryden Western 3 years from 2012 4 out of 4

Paul Hopkinson Western 3 years from 2013 3 out of 4

Jacqueline Lockwood Western 3 year from 2013 4 out of 4

Lynn Ritchie Western 3 years from 2014 1 out of 1

Mary Summers Western 3 years from 2012 2 out of 4

Paul Tinnion*** Western 3 years from 2011 3 out of 3

Alan Dougall Eastern 3 years from 2014 1 out of 1

Brian Hewitt Eastern 3 years from 2013 3 out of 4

Margaret Jobson Eastern 3 years from 2011 4 out of 4

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Public Governors Constituency Appointment Meetings Attended

Bill Lee**** Eastern 3 years from 2012 3 out of 3

Patient Governor Constituency Appointment Meetings Attended

Vacant Position

Staff Governors Constituency Appointment Meetings Attended

Faye Butler Staff 3 years from 2013 3 out of 4

Sam Dae Staff 3 years from 2012 1 out of 4

Alison Griniezakis Staff 3 years from 2013 2 out of 4

Ian Stafford Staff 2 years from 2013 4 out of 4

Carole Turnbull Staff 3 years from 2013 2 out of 4

VACANCY Staff

Appointed Governors Organisation Appointed Meetings Attended

Alan Baty***** Gateshead PCT February 2012 0 out of 2

Dan Cowie Gateshead CCG September 2013 1 out of 2

Sarah Gascoigne Gateshead Youth Council November 2013 2 out of 2

John Hamilton Gateshead Council January 2008 3 out of 4

Ashok Kumar Gateshead Diversity Forum February 2014 0 out of 0

Kath McCourt University of Northumbria September 2006 1 out of 4

James Miller GVOC February 2013 3 out of 4

Hastings Ndlovu** Gateshead Diversity Forum May 2011 1 out of 3

Mark Pearce University of Newcastle November 2011 2 out of 4

Aron Sandler Gateshead Jewish Community May 2009 2 out of 4

Richard Thorold Gateshead College November 2008 2 out of 4

* Candidate did not stand for re‐election ** Governor resigned from post mid‐term *** Governor could not stand for re‐election as they had served the maximum of 9 consecutive years **** Governor had to resign mid‐term due to serving the maximum of 9 consecutive years ***** Appointing organisation ceased to exist Through its Governors and members, the Trust is making links with local communities to gain a greater understanding of people’s needs to shape services.

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It has been a busy year for the Council of Governors. They have fulfilled a number of formal functions and have also been contributing to the organisation through their representation on the Board sub‐committees. Elections Held During 2013/14 Elections in both public and staff constituencies are undertaken on behalf of the Trust by the Electoral Reform Ballot Services Limited which is engaged to act as the Returning Officer and Independent Scrutineer for the election process of Gateshead Health NHS Foundation Trust. Elections for two staff and nine public governors, whose tenure of office ended on 4 January 2014, were held during 2013/14. The results were announced on 13 December 2013 as follows: Staff Governors Mrs Faye Butler was re‐elected unopposed for a 3 year tenure 1 vacancy remains Public Governors ‐ Western Constituency Mr John Rae was elected for a 3 year tenure (subsequently resigned on 18 February 2014) Miss Lynn Ritchie was elected for a 3 year tenure Public Governors ‐ Central Constituency Mrs Eileen Adams was elected for a 3 year tenure Mr John Bolam was elected for a 3 year tenure Mrs Sheila Gallagher was elected for a 3 year tenure Professor Teresa Waring was elected for a 3 year tenure Public Governors ‐ Eastern Constituency Mr Alan Dougall was elected for a 2 year tenure Mrs Margaret Jobson was re‐elected for a 3 year term Patient Governor 1 vacancy remains Related Party Transactions The members of the Council of Governors have completed the required declaration forms and none of the governors or parties related to them has undertaken any material transactions with Gateshead Health NHS Foundation Trust. Register of Interests The register of Governors’ interests is available for inspection by members of the public. Details on how to view the register are shown on the back cover of this report. Expenses Governors may claim expenses at public transport rate for travel at 40p per mile and other reasonable expenses.

55

Membership Membership of Gateshead Health NHS Foundation Trust is made up of three constituencies; Public, Patient and Staff. Public Members: Those eligible to become public members are people over the age of 16 who live in Gateshead and the immediate surrounding area which is divided into three constituencies; Western, Central and Eastern Gateshead, and the Out of Area constituency which includes County Durham, Newcastle, North Tyneside, Northumberland, South Tyneside and Sunderland (other than areas within the Gateshead constituency).

The map above shows the boundaries for the public membership People over 16 years of age, living in these areas who wish to become a public member of Gateshead Health NHS Foundation Trust, must complete and have accepted a membership application form. Members can vote to elect governors for their constituency and can choose to be nominated to stand for election as a governor.

Population/Public Membership Ratio at 31 March 2014 Western Central Eastern TOTAL

Population 77,471 92,828 41,615 211,914

Membership 3,601 6,312 2,245 12,158

% 4.65% 6.79% 5.39% 5.74%

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At the end of March 2014, there were 76 Out of Area public members. Patient Members: In March 2009, the Trust’s constitution was amended to create an out‐of‐area patients’ constituency. Patient members are those who live outside the area of Public Membership, who are over the age of 16 years and have at any time during the seven years immediately preceding the date of their application been a patient of the Trust. Carers of patients who meet these criteria are also eligible to become Patient Members. At the end of March 2014, there were 280 patient members. Staff Members: Staff directly employed by the Trust are automatically members for the duration of their employment, unless they choose to ‘opt out’. Staff whose services are contracted for by the Trust, staff not employed by the Trust but who in effect work in and with the Trust for most of their time and volunteers are given the same status as staff, if they wish, provided they have worked with the Trust for a minimum of one year. Employees of the Trust cannot be public members. Membership Numbers: As at 31 March 2014 the total number of public members was 12,234, an increase of 83 members since April 2013. The total number of patient members was 280. The number of staff members was 3,500. The chart below shows the number of members per constituency:

Membership Strategy: The Council of Governors Membership Strategy Subgroup was established in 2005 to: • Agree a membership recruitment campaign

2245

6312

3601

280 76

3500

0

1000

2000

3000

4000

5000

6000

7000

Eastern Area Central Area WesternArea

Patient Out of TrustArea

Staff

Membership Totals (as at 31st March 2014)

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• Review membership by number, age, ethnicity and gender by constituency • Actively recruit members to the Trust from their own constituency • Attend meetings/functions to raise awareness of Gateshead Health NHS Foundation Trust • Report to the full Council of Governors the position statement of membership and the

achievements of the recruitment campaign • Update the membership strategy and agree this with the full Council of Governors During 2013/14, the working group was involved in the following activities: • holding regular recruitment sessions in the Out Patients department • promoting membership at five Medicine for Members events recruiting new members • reviewing the membership strategy • undertaking regular recruitment mailshots to new patients and staff leaving the Trust • reviewing the membership of the group and its terms of reference As at 31 March 2014, our public membership was as follows:

PopulationDemographics

Membership Demographics

Gender

Male 48.4% 39.0%

Female 51.6% 60.9%

Unknown 0.1%

Age

Under 16* 19.3%

16 – 19 4.9% 1.2%

20 – 29 11.4% 9.0%

30 – 59 41.6% 36.6%

60 – 74 15.2% 30.7%

75 and over 7.6% 21.3%

Age unknown 1.1%

Ethnic Breakdown

White 98.4% 93.2%

Other 1.6% 2.4%

Unspecified 4.4% *not able to become members

We are committed to ensuring that NHS Foundation Trust membership is representative of the whole community. We welcome membership applications from persons of any age (over 16), whatever their race, colour, religious beliefs, ethnic or national origin, gender, disability or marital status. Analysis of membership in the tables above shows that ethnic makeup is higher than that of the Gateshead demographics. The membership is over represented by people aged over 60 and is under represented in all other age groups. It is also over represented by females.

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Communication and Involvement of Members We use a variety of approaches to recruit and engage with our members. In particular we recruit new members via governors engagement at Out‐Patient clinics held within the hospital, as a result of community engagement by our public governors and via our website. In 2013/14 a plan has been agreed by Governors to increase their engagement with Members through local community events. This gives members a greater opportunity to give their feed‐back to the Trust on new or revised services. Members also receive a joint members and staff newsletter, QE News which is published three times a year and sent to members via email or post. Our greatest success in involvement is our Medicine for Members programme of seminars and five of these were held during 2013/14. Topics included Stroke, Organ Donation, Hip Replacements, Thyroid Disease and Lung Disease. A total of 219 members attended the events and feedback was, once again, extremely positive. Comments included: “Very engaging and informative speaker and interesting presentation” “Keep up the good work – really interesting and information lecture” “Always find these events of benefit – keep up the good work – thank you” “A very simplified but succinct presentations on a complex subject” “This was one of the best lectures I have attended” “It was a very interesting talk. I enjoyed it very much” Future engagement activity will include: • Sending out regular members’ e‐bulletin • Promoting the use of dedicated email address – [email protected] to contact local

governors • Use of internal communication mechanisms to promote the role of staff governor • Continuing to hold regular engagement events • Increased use of social media (twitter) as a way to engage

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Disclosure of Corporate Governance Arrangements

Provision Requirement Location / Section of Report

A.1.1 This statement should also describe how any disagreements between the Council of Governors and the Board of Directors will be resolved. The annual report should include this schedule of matters or a summary statement of how the Board of Directors and the Council of Governors operate, including a summary of the types of decisions to be taken by each of the Boards and which are delegated to the executive management of the Board of Directors

Governance Report

A.1.2 The annual report should identify the Chairperson, the Deputy Chairperson (where there is one), the Chief Executive, the Senior Independent Director (see A.4.1) and the Chairperson and members of the nominations, audit and remuneration committees. It should also set out the number of meetings of the Board and those committees and individual attendance by Directors

Governance Report

A.5.3 The annual report should identify the members of the Council of Governors including a description of the constituency or organisation that they represent, whether they were elected or appointed, and the duration of their appointments. The annual report should also identify the nominated Lead Governor.


Additional Requirement of FT ARM

The annual report should include a statement about the number of meetings of the council of governors and individual attendance by governors and directors.


B.1.1 The Board of Directors should identify in the annual report each Non‐Executive Director it considers to be independent, with reasons where necessary.

Governance Report

B.1.4 The Board of Directors should include in its annual report a description of each Director’s skills, expertise and experience. Alongside this, in the annual report, the Board should make a clear statement about its own balance, completeness and appropriateness to the requirements of the NHS Foundation Trust.

Governance Report


The annual report should include a brief description of the length of appointments of the non‐executive directors, and how they may be terminated.

Governance Report

B.2.10 A separate section of the annual report should describe the work of the nominations committee(s), including the process it has used in relation to Board appointments.

Governance Report

60



The disclosure in the annual report on the work of the nominations committee should include an explanation if neither an external search consultancy nor open advertising has been used in the appointment of a chair or non‐executive director

Governance Report

B.3.1 A Chairperson’s other significant commitments should be disclosed to the Council of Governors before appointment and included in the annual report. Changes to such commitments should be reported to the Council of Governors as they arise, and included in the next annual report.

Governance Report

B.5.6 Governors should canvass the opinion of the Trust’s members and the public and for appointed Governors the body they represent, on the NHS Foundation Trust’s forward plan, including its objectives, priorities and strategy, and their views should be communicated to the Board of Directors. The annual report should contain a statement as to how this requirement has been undertaken and satisfied.



If, during the financial year, the Governors have exercised their power* under paragraph 10C** of schedule 7 of the NHS Act 2006, then information on this must be included in the annual report. This is required by paragraph 26(2)(aa) of schedule 7 to the NHS Act 2006, as amended by section 151 (8) of the Health and Social Care Act 2012. *Power to require one or more of the directors to attend a governors’ meeting for the purpose of obtaining information about the foundation trust’s performance of its functions or the directors’ performance of their duties (and deciding whether to propose a vote on the foundation trust’s or directors’ performance). **As inserted by section 151(6) of the Health and Social Care Act 2012)

Governors have not exercised this power

B.6.1 The Board of Directors should state in the annual report how performance evaluation of the Board, its committees, and its Directors, including the Chairperson, has been conducted.

Remuneration Report

B.6.2 Where an external facilitator is used for reviews of governance, they should be identified and a statement made as to whether they have any other connection with the Trust.

N/A for 2013/14

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C.1.1 The Directors should explain in the annual report their responsibility for preparing the annual report and accounts, and state that they consider the annual report and accounts, taken as a whole, are fair, balanced and understandable and provide the information necessary for patients, regulators and other stakeholders to assess the NHS Foundation Trust’s performance, business model and strategy. There should be a statement by the external auditor about their reporting responsibilities. Directors should also explain their approach to quality governance in the Annual Governance Statement (within the annual report).

Strategic Report And Annual Governance Report

C.2.1 The annual report should contain a statement that the Board has conducted a review of the effectiveness of its system of internal controls.

Annual Governance Statement

C.2.2 A Trust should disclose in the annual report: (a) if it has an internal audit function, how the function is

structures and what role it performs; or (b) If it does not have an internal audit function, that fact and the

processes it employs for evaluating and continually improving the effectiveness of its risk management and internal control processes.


C.3.5 If the Council of Governors does not accept the audit committee’s recommendation on the appointment, reappointment or removal of an external auditor, the Board of Directors should include in the annual report a statement from the audit committee explaining the recommendation and should set out reasons why the Council of Governors has taken a different position.

N/A for 2013/14

C.3.9 A separate section of the annual report should describe the work of the committee in discharging its responsibilities. The report should include:

• The significant issues that the committee considered in relation to financial statements, operations and compliance, and how these issues were addressed;

• An explanation of how it has assessed the effectiveness of the external audit process and the approach taken to the appointment or re‐appointment of the external auditor, the value of external audit services and information on the length of tenure of the current audit firm and when a tender was last conducted; and

• If the external auditor provides non‐audit services, the value of the non‐audit services provided and an explanation of how auditor objectivity and independence are safeguarded.


62


D.1.3 Where an NHS Foundation Trust releases an Executive Director, for example to serve as a Non‐Executive Director elsewhere, the remuneration disclosures of the annual report should include a statement of whether or not the Director will retain such earnings.

Not Applicable

E.1.5 The Board of Directors should state in the annual report the steps they have taken to ensure that the members of the Board, and in particular the Non‐Executive Directors, develop an understanding of the views of Governors and members about the NHS Foundation Trust, for example through attendance at meetings of the Council of Governors, direct face‐to‐face contact, surveys of members’ opinions and consultations


E.1.6 The Board of Directors should monitor how representative the NHS Foundation Trust’s membership is and the level and effectiveness of member engagement and report on this in the annual report.


E.1.4 Contact procedures for members who wish to communicate with governors and/or directors should be made clearly available to members on the NHS foundation trust’s website and in the annual report.

Contact Details Back Page

Additional requirement of FT ARM

The annual report should include: • A brief description of the eligibility requirements for joining

different membership constituencies, including the boundaries for public membership;

• Information on the number of members and the number of members in each constituency; and

• A summary of the membership strategy, an assessment of the membership and a description of any steps taken during the year to ensure a representative membership, including progress towards any recruitment targets for members


Additional requirement of FT ARM

The annual report should disclose details of company directorships or other material interests in companies held by governors and/or directors where those companies or related parties are likely to do business, or are possibly seeking to do business, with the NHS foundation trust. As each NHS foundation trust must have registers of governors’ and directors’ interests which are available to the public, an alternative disclosure is for the annual report to simply state how members of the public can gain access to the registers instead of listing all the interests in the annual report.

Governance Report

63

Comply or Explain The trust is satisfied that it complies with the provisions of the code with the exception of point B.2.4 below B.2.4 The Chairperson or an

independent Non‐Executive Director should Chair the nominations committee

The Trust’s Governors’ Remuneration Committee which advises the Council of Governors on appointment and remuneration of Non‐Executive Directors is chaired by a nominated governor. The Council of Governors, with the support of the Chairman of the Trust, has recently confirmed that this is the appropriate governance model, due to the potential conflict of interest of the Chairman in the decisions taken by the Committee.

64

Quality Account 2013/14

65

Contents 1. Achievements in Quality in 2013/14 ............................................................................................ 67

Statement on Quality from the Chief Executive ........................................................................... 68 2. Priorities for Improvement ........................................................................................................... 70 2.1 Reporting back on our progress in 2013/14 ................................................................................. 70 2.2 Our Quality Priorities for Improvement in 2014/15 ..................................................................... 92 2.3 Statements of Assurance from the Board .................................................................................... 107 2.4 Mandated Core Quality Indicators ............................................................................................... 128 3. Review of quality performance .................................................................................................... 137 3.1 Patient Safety ............................................................................................................................... 137 3.2 Clinical Effectiveness .................................................................................................................... 142 3.3 Patient Experience ........................................................................................................................ 147 3.4 Focus on Staff ............................................................................................................................... 158 3.5 Quality overview ‐ performance of Trust against selected indicators ......................................... 163 3.6 National targets and regulatory requirements ............................................................................ 174 4. Feedback on our 2013/14 Quality Account .................................................................................. 176 Annex: Statement of directors’ responsibilities in respect of the quality account .................................. 179 Glossary of Terms ...................................................................................................................................... 180 Appendix A: Participation in National Clinical Audits and National Confidential Enquiries ................ 184 Appendix B: Independent Auditor’s Report to the Board of Governors of Gateshead Health NHS

Foundation Trust on the Quality Report .......................................................................... 186

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Statement on Quality from the Chief Executive It is my pleasure to introduce to you the fifth Quality Account to be published by Gateshead Health NHS Foundation Trust. Despite the difficult environment which the NHS faces, both financially and in terms of service quality in the post‐Francis Review world, QE Gateshead remains committed, from Ward to Board, to providing safe services and high quality care for our patients. I am therefore pleased to report that the Quality Account for 2013/14 once again reflects another excellent year for the Trust in our pursuit of this ambition. Our success is most obviously reflected in the feedback we received from Care Quality Commission following their unannounced inspection in December 2013. This confirmed that we were meeting all of the essential standards of quality and safety, and their report did not identify any areas of concern or for improvement. Alongside this, the CQC also rated us a band 6 trust, the best rating available, making us one of the safest and high performing hospitals in the country. Our work was also highlighted by Dr Foster Hospital Guide 2013. We were one of a number of Trust’s to receive a ‘Highly Commended’ award for our work to improve weekend hospital readmissions since 2011/12. We are also delighted that we were placed 1st for the whole of England in our recent Cancer Patient Experience Survey, which measured patients’ experience of services whilst being treated in hospital. Recognition of this nature is clearly a very welcome confirmation of our continued efforts to drive up the quality, safety and effectiveness of the care we provide on a daily basis. However, it is absolutely acknowledged by the Trust Board that it is only possible with the hard work of our staff, and their daily commitment to the Trust’s Vision and core values. We have regularly monitored our improvement plans during 2013/14 through our Patient, Quality and Risk and Safety Committee and the Trust Board. In addition to the examples detailed above, the Quality Account for 2013/14 reflects the excellent progress we have made against our priorities for the year. Examples: • Reducing missed doses of critical medicines; • Improving our mortality rates and implementing our Mortality Reduction Strategy that focuses on

strong clinical leadership, improving the quality of clinical care as well as the quality of our documentation and data;

• Implementing the 15 Step Challenge which has given us the opportunity to see our services, and therefore identify areas for improvement, through the patient’s eyes; and

• Maintaining a positive patient safety culture as demonstrated through our recent patient safety culture (MaPSaF) assessment.

Whilst we have made significant progress in some key areas over the past year we are not complacent and recognise that we can always do better. We will therefore continue our quality journey through the delivery of our SafeCare Strategy 2014/17 that sets out how we will continue to deliver improvements over the next three years, alongside our six key priorities reflected in our Quality Account for 2014/15: Clinical Effectiveness • Reduce avoidable deaths in hospital • Improve the care of patients living with a diagnosis of Dementia and creating a Dementia friendly

hospital Patient Safety • Reduce inpatient falls that cause harm to patients

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2. Priorities for Improvement

2.1 Reporting back on our progress in 2013/14 In our 2012/13 Quality Account we identified six quality improvement priorities that we would concentrate on in 2013/14. This section focuses on the progress we have made against these.

We achieved our aims

We partially achieved our aims or significantly improved our processes to enable future improvement

We did not achieve our aims

Clinical Effectiveness

Priority 1 Continue to focus on reducing avoidable deaths in hospital

What did we say we would do? Achieve a year on year reduction in mortality utilising the crude mortality rate, a risk adjusted mortality index and the Summary Hospital‐level Mortality Indicator (SHMI). Our aim was to achieve lower than expected or as expected SHMI banding. Explanation of how mortality is measured: Like many other Trusts, the Trust uses an independent organisation called Dr Foster to monitor its Hospital Standardised Mortality Ratio. The Hospital Standardised Mortality Ratio (HSMR) compares the expected rate of death in a hospital with the actual rate of death and allows us to assess the Trusts performance on a range of clinical conditions, such as patients with conditions that most commonly result in death for example, heart attacks and strokes. The Summary Hospital‐level Mortality Indicator (SHMI) is similar to the HSMR but this takes into consideration out of hospital deaths that have occurred within 30 days of discharge from hospital. The SHMI whilst calculating a score places each Trust into one of three bands for mortality rating. Table illustrating how the risk adjusted scores are interpreted:

Interpretation of score HSMR value SHMI band

Deaths as predicted 100 ‘as expected’

More deaths than predicted Score greater than 100 ‘high’

Less deaths than predicted Score less than 100 ‘low’ Crude mortality rate is a measure of the number of deaths which does not include an adjustment for risk factors as in the HSMR. The crude rate is the percentage of deaths that have occurred out of all hospital spells (stays).

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Did we achieve it?

The Summary Hospital‐level Mortality Indicator (SHMI) reports mortality at a trust level across the NHS in England and is regarded as the national standard for monitoring of mortality. The main development in measuring mortality that the SHMI takes into account is patient deaths outside of hospital within 30 days of discharge from hospital. Previous indicators have focused purely on in hospital deaths. The SHMI is produced quarterly with the first publication made in October 2011. The SHMI categorises trusts into one of three groups based on the Trust SHMI calculation; low, as expected and high. For all of the SHMI calculations since October 2011, death rates (mortality) for QE Gateshead are described as being ‘as expected’.

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In last year’s quality account the Trust demonstrated a year on year reduction in risk adjusted mortality utilising the RAMI which is the signature mortality measure used by CHKS our previous clinical data system supplier. In 2013 the Trusts contract with CHKS came to an end and in June 2013 the Trust purchased the Dr Foster system. One of the key advantages to Dr Foster was the in‐depth information around mortality and the ability to see the data that underpins many of the publications related to hospital death rates. This was seen as an opportunity by the Trust to better understand the conclusions reached by other data providers and realise opportunities for learning and improving patient care. The move to Dr Foster and their risk adjusted mortality rate (HSMR) illustrates that a year on year reduction from 2008/09 has not been achieved. However encouragingly from 2011/12 the Trust has shown year on year reduction in the death rates to a position in 2013/14 which is currently showing less than expected deaths occur (as a guide a score of 100 suggests deaths are exactly at the expected rate). This is reflective of the continuing work undertaken in the Trust to reduce mortality and improve patient care.

The pattern demonstrated for crude death rates shows a downward trend with the exception of a slight increase in 2012/13. The historic rates differ to those previously published in our quality account as a result of the difference in activity collection between Dr Foster and CHKS. Dr Foster looks at activity in a way that reflects the patients full hospital experience, even if this spans more than one hospital (known as a superspell). So if a patient is admitted to Hospital A then transferred to Hospital B where they died, the system acknowledges the fact that the death could be a result of the care at Hospital A and not just the Hospital in which they died. CHKS would only ever allocate deaths to the hospital where the patient died.

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How did we achieve it? We built on our existing work by developing a mortality reduction strategy to guide us on the next phase of our work in reducing avoidable mortality over the next three years. The strategy focuses on three areas for change recognised to be important to reducing in‐ hospital mortality: 1. Leadership ‐ The organisation has the data, reporting and leadership skills it needs to manage and

improve standardised mortality • We have reviewed the provision of information and data the Board receives related to

mortality to ensure its usefulness in informing decision making. • We have continued to review and refresh our mortality governance arrangements to

ensure that these are embedded in the organisation. Our aim is that leaders at all levels of the organisation and in all clinical areas are continuously and actively engaged in activities to reduce avoidable mortality.

• We have focused on identifying mortality leads in each business unit and developing the capability and capacity within the services for mortality review, learning from reviews and dissemination of this across the organisation. This has included our Medical Director attending mortality review workshops to gain further insight into additional ways of structuring and learning from mortality reviews.

• We have worked with other Trusts in the region to share knowledge, learning and develop discrete pieces of work to help us understand where improvements can be made.

2. Improving Clinical Care and pathways‐ provide safe, evidence based care

To deliver care that is safer, more effective, and that provides a better experience for patients we have focused on three key areas: • Clinical Review of deaths • Developing seven day services • Effective and Safe Handover Clinical Review of Mortality • We have strengthened our processes related to review of deaths across the Trust to ensure

that all services are included and that feedback and emergent learning is shared through the Mortality and Morbidity Steering group

• We have reviewed and refreshed the documentation that is used for the review of mortality. This now facilitates better identification of key learning and areas where action must be taken.

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• Based on our review of deaths the Mortality and Morbidity Steering Group have set clinical priorities and commissioned reviews of clinical care where there has been potential for improvement. We have also carried out some focused work on reviewing the care of patients with specific conditions where our mortality data has appeared higher than expected.

• Some examples of where improvements in care have been made as a consequence of our reviews include:

• the development of our Non Invasive Ventilation service for patients with Chronic

Obstructive Airways Disease • the development and implementation of new clinical guidelines for patients

presenting to hospital with severe headache, this includes enhanced fast track to CT scanning out of hours

Learning from mortality review process

Developing seven day services • With the aim of improving patient access to clinical services we have begun to review which

services can be extended to be delivered seven days a week in a sustainable way. As a first stage, the review has been focusing on improving access to diagnostic tests and urgent and emergency care.

• We have focused on ensuring our emergency care pathways operate effectively over seven days, including bank holidays and good progress has been made. Services across the organisation are currently assessing against the DOH model for seven day services and formulating their plans.

• To ensure we have the necessary medical staffing additional doctor posts have been established on the elderly care ward and nurse staffing levels are currently being reviewed. A Lead Acute Physician post has also been established to provide greater speciality input to the wards at weekends and bank holidays.

• The Trust is also working with primary care to develop an integrated pathway for frail elderly patients that not only meets the needs of service users and carers but also maximises the efficiency of integrated working. Gateshead CCG has agreed to fund an interface Geriatrician in A&E and MAU to work with the frailty team. This means that frail

Case review meetings within clinical services

Key learning and actions identified and collated using new summation documentation

Collated information to

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review on monthly basis

Key findings presented at Mortality &

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agreed

Progress on identified action reported back to

Mortality & Morbidity

Steering Group

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elderly patients presenting at A&E or MAU can be assessed on admission by a specialist physician enabling more timely and appropriate care.

Safe Handover Effective communication is integral to good patient care and this work stream is focusing on the effective and safe handover of patients at each point of their care. Ensuring medical diagnosis and treatment plans are clear at the point of patient handover is key. A further aim is the handover of particularly unwell patients by doctors to base ward medical teams. We have begun to assess how the use of patient passports can be implemented into the patients’ pathway. One approach that is being developed is integrating the key information for handover into the existing medical admissions unit documentation which makes explicit any outstanding investigations, current and new medications and instruction for ongoing care.

3. Documentation and Informatics ‐ patient documentation and coding is accurate, includes all

relevant clinical information and is used effectively to improve care • We have provided a programme of education and training to ensure our staff have the skills

and knowledge to gain maximum benefits from the Dr Foster system. • We have developed standard procedures which set out clear guidelines for documentation

and recording of Palliative Care coding. This procedure includes a validation process to monitor compliance.

• The Clinical Coding team have all completed refresher foundation training, an internal audit focussing upon patients with a primary diagnosis of a sign and symptom code has also been completed. Following the audit the lessons learned have been fed back to individual team members.

• A programme of training sessions to educate the clinical teams on the importance of clinical documentation and coding has been implemented. This has been supported by SafeCare Good Practice Bulletins, staff newsletters and screensavers.

• The Medical Director and Clinical Coding Manager have established a programme of Divisional Consultant Meetings. These sessions complement the work that is on‐going within the coding awareness programme, but focuses more specifically upon mortality and documentation relating to signs and symptoms.

• The Clinical Coding Department are also working with the Mortality Task and Finish Group to agree a process that will include the validation of Clinical Coding for deceased patients as part of the Trusts mortality reviews. This is commencing within respiratory and orthopaedics services. Thereby further ensuring that the information the Trust report relating to mortality is of the highest standard possible. A Clinical Coding Task and Finish Group has also been set up, this group will look at a number of areas relating to clinical coding, which will include supporting work on mortality, this group includes representation from directors, clinicians and the clinical coders.

• A new method for recording Cause of Death data electronically has been developed and this is also included in the information that is sent to GP’s.

Our work on reducing avoidable mortality will continue in 2014/15.

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Priority 2 Reduce avoidable readmissions to hospital within 30 days of discharge

What did we say we would do? A number of patients return to hospital within 30 days of discharge. For some patients this further admission is not linked to their recent hospital stay, but for others they have to return to hospital because of complications following their discharge. The Trust set itself a two‐five year ambitious plan to reduce readmissions overall by 25% to align Trust level readmission rates with best practice. The aims were to implement work streams based on findings from an initial audit conducted in 2011/12, where 30‐31% of the Trust’s readmissions were ‘avoidable’. We said we would continue our work around the themes identified in 2012/13 which were: • Prevention of admission Strategies: • Ensuring Acute Care is optimised to prevent avoidable admissions • Integration and development of outreach and in‐reach teams to provide supportive best care to

prevent avoidable admissions Did we achieve it? As the Trust has a two‐five year plan of achieving a 25% reduction in readmissions within 30 days the measure for achievement will be the volume of readmissions and associated reduction from the baseline year of 2011/12. Dr Foster has been used to assess this indicator as it has the capability to broaden the analysis for patients not only readmitted to Gateshead but to any other hospital in the country. Whilst this may give higher volumes of readmissions for the Trust as it looks at other hospital activity, this is extremely important from a wider health economy perspective and crucially a more accurate reflection of true patient readmissions to hospital. So what does a 25% reduction look like:

2011/12 readmissions within 30 days Achieving a 25% reduction 5,542 4,156

A reduction of 1,386 readmissions on the 2011/12 data would equate to a 25% reduction. The chart below depicts the current volumes of readmissions within 30 days from 2011/12.

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To provide a useable figure for the year end position in 2012/13 a forecasted number of readmissions have been calculated for the full 12 months. Currently the year to date position includes data to October 2013. The setting of the target in 2011/12 meant that in 2012/13 much of the work taking place was around getting funding, processes, and resources in place. As these processes and resources are becoming embedded into the health economy there is evidence that reductions in readmissions is happening with an estimated 6.5% reduction by 2013/14 year end. The Trust will continue to monitor this indicator and endeavour to achieve the goal of a 25% reduction in the remaining years of the five year plan. As supporting information the chart below depicts the rate of readmissions within 30 days against all hospital inpatient activity.

How did we achieve it? Following the reforms of the Health & Social Care Act 2012, replacing Primary Care Trusts with the Clinical Commissioning Groups (CCG), our traditional work programmes, models of working, and how the Trust accesses readmissions funding have been subject to change. Reducing readmissions, forms part of Gateshead’s CCG’s Urgent Care Programme. Subsequently the re‐alignment of our internal readmissions and emergency care work streams to ‘best fit’ with the Urgent Care agenda has been a challenge in 2013/14. In addition the changes in the governance structures and financial flows have resulted in delays with the existing project and in agreeing funding to commence new projects and trials. The intended plan for 2013/14 had been to continue some of the improvement plans and readmission themes from 2012/13. Operational Workgroups consisted of: • Challenging Behaviour Team; • Streamlining Discharge; • Development of the Falls Team; • A&E Frailty Pilot; • Development of Hospital Based Alcohol Team; • Psychology Support for CBT, and • Tele‐health Nurse to support patients with COPD.

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The work streams leads presented to an evaluation panel in June 2013. Whilst the CCG acknowledged the excellent programmes of work, further funding for the pilot areas was not agreed and this impacted on our ability to progress some of this work. However the work that we have undertaken to date has presented opportunities for learning and has resulted in improvements in patient flow and reduction in readmissions to hospital. Prevention of admission Strategies: Patients with alcohol related illness We have progressed our work in relation to the development of drug and alcohol services: • We have embedded the pathways of care and clinical guidelines we developed for patients

requiring alcohol detoxification. • We have continued to focus on clinical staff education on providing brief intervention training and

appropriate referral to specialist alcohol services. Our monthly programme of clinical audit has demonstrated excellent compliance with undertaking patient assessments and on‐going referral where appropriate.

• The hospital alcohol team have continued to provide an outreach service to patients with liver cirrhosis who are deemed as requiring extra support for a period of time

• Our community drug and alcohol link now sees patients in ward areas prior to their discharge. This ensures support services are in place for patients at the point of discharge.

Ambulatory Care Model Development The Trust implemented an ambulatory care clinic which is situated near the medical assessment area. The aims of the clinic are to prevent admission and review patients via an emergency day care facility. The clinic has enabled patients presenting with suspected VTE, lower limb cellulitis and anaemia to be assessed and appropriate care provided without the need for admission to hospital. This has been supported by the development of clinical protocols and guidelines. Optimisation of Acute Care to prevent avoidable readmission: We continued our work on improving patient flow and length of stay by streamlining the discharge process. An estimated date of discharge is established for all patients within 12 hours of admission which should be a ‘live’ date being regularly reviewed and updated throughout the inpatient stay. All patient care plans and discharge plans are co‐ordinated by undertaking two multidisciplinary ‘board rounds’ each day involving nursing, medical staff, allied health professionals and social workers. The 8 am board round focuses on the necessary actions to facilitate a patient’s discharge, whilst the 3 pm board round provides the key members of the team with an update of the progress achieved during the day and allows for some last minute or urgent actions to be followed up. There is an identified discharge nurse on each ward whose role is to co‐ordinate the whole process.

Integration and development of outreach and in‐reach teams: An audit identified that over 60% of patients over 75 years were admitted to hospital via Accident and Emergency. Patients aged 75‐85 years account for the largest groups of patient readmitted to our hospital.

When all of the essentials are in place the process works well and we can demonstrate

improvements Ward Manager

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A project was developed to reduce delays in care, retain resources locally and provide continuity of care for patients across hospital and community services. We have focused on developing clear pathways for this group of patients including those not admitted to an older persons ward to ensure that patients with frailty are identified and managed with supported discharge and community follow up to prevent avoidable readmissions to hospital. In October the Trust was invited to re‐bid for readmission funding. The following table details the resulting work streams which were approved in December 2013. This work is now being developed and will be progressed throughout the coming year.

Project Patient Centred Care Younger Complex Patients E‐ Prescribing Developing Heart Failure Developing Ambulatory Care Rapid Access & Treatment / Coordination & flow Acute/ Geriatrician

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Priority 3 Improve the care of patients living with a diagnosis of Dementia and creating a dementia friendly hospital

The Prime Minister’s Challenge on Dementia identified that one in three people over 65 will have dementia by the time they die and as life expectancy increases more and more people will be affected. As many as half of all dementia sufferers in this country are unaware that they have the condition which means that they cannot get the help that they or their family need. We set ourselves a challenge to meet the requirements of becoming a dementia friendly hospital by 2016 through the delivery of our Dementia Work Programme. Over the past year we have continued to progress this important work to ensure that patients with a dementia are provided with the best possible care that meets their specific needs. What did we say we would do? 1. A ward environmental programme will be produced to audit all existing wards and departments

within the Queen Elizabeth Hospital 2. Produce a Trust environmental action plan 3. Plan a staff interactive dementia workshop 4. Roll out the ‘Forget Me Not’ programme and include patient identity wristbands

1. A ward environmental programme will be produced to audit all existing wards and

departments within the Queen Elizabeth Hospital Did we achieve this? Yes we did How did we achieve it? We produced a ward and departmental environmental programme for dementia. The roll out of the programme is underway and 12 areas in the Trust have already had an environmental audit completed by members of the Dementia Environmental Sub Group. Local action plans have been produced for these areas and have included: • new dementia friendly signage • non reflective flooring • mute coloured painting • large faced clocks • better control of lighting • coloured toilet seats Both the University of Sterling Dementia Environmental Audit Tool and the Kings Fund London Dementia Audit Tool have been used by the sub group members. The University of Sterling toolkit has been used for specialist dementia wards and departments and the Kings Fund Tool for all other areas within the Trust. As part of the programme ward managers undertake the audit programme training.

2. Produce a trust environmental action plan Did we achieve it? Yes we did

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How did we achieve it? In line with the Trust’s Dementia Work Programme 2013/16 the Dementia Steering Group has been restructured and now comprises of four work streams with senior leads for each. • Delivering CQUIN indicators that focus on improving dementia and delirium care, including

sustained improvement in finding people with dementia, Assessing and Investigating their symptoms and Referring for support (FAIR).

• Education and Training • Dementia Environment • Nutrition The Dementia Environmental work stream is chaired by the Director of Estates with staff representation from the Trust including the four dementia environmental sub group members. This work stream has produced a Trust environmental action plan that has incorporated all wards and departments at the Queen Elizabeth, Bensham and Dunston Hill Day Hospital to support them becoming dementia friendly, as part of the Trust’s overall objective to be a dementia friendly hospital. This is part of the national drive to involve local communities in meeting the needs of people with dementia in society as a whole. As part of the Trusts environmental action plan, a successful bid was made in 2013 to the Department of Health for dementia environmental funding for three areas within the Trust: • Jubilee Day Unit Outpatient facilities • Woodside Unit • Cragside Court

The grant has been used to significantly improve all three environments and the work will be completed in April 2014.

3. Plan a staff interactive dementia workshop

Did we achieve it? Yes we did

How did we achieve it? We held a staff interactive training day on Dementia in July 2013. Participants included nursing and medical staff, physiotherapists, psychology staff and housekeepers with over 30 staff attending. Staff were allocated into groups and spent the day participating in workshops as well as visiting wards and departments within the hospital identifying areas for improvement for dementia patients. There were a number of ‘bright’ ideas that emanated from the workshops including the use of red medicine pots during ward drug rounds. A pilot was undertaken on Ward 25 using the red pots for patients with dementia. The colour was visual to this group of patients and proved extremely successful on the ward. This had now been rolled out to other wards within the Trust. In addition to the workshop the Trust took the decision to embark on a major programme to train as many staff as possible over the next year and on‐going, on what our older patients need from us. ‘Barbara’s Story’ is a powerful film around one woman’s experience of NHS care. We are asking staff to commit, as our Board have, to learning from Barbara. Watching this film as part of a planned session is now mandatory training for every member of staff in the Trust.

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4. Roll out the ‘Forget Me Not’ programme and include the patient identity wristbands Did we achieve it? Unfortunately the roll out of the ‘Forget Me Not’ programme was postponed as part of the re‐launch of the Trust Dementia Strategy. We will start rolling out the ‘Forget Me Not’ scheme in May 2014 in line with a number of other dementia initiatives that forms part of our overall strategy.

The ‘Forget Me Not’ will include providing information for patients and carers on what the scheme entails. Patients will wear a blue wristband with the words ‘Forget me Not’ printed on it in white letters once they or their relative has signed up to the scheme. This will enable all staff within the hospital to identify patients with dementia who require additional help and assistance during their stay in hospital.

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Patient Safety

Priority 4 Reduce omitted doses of Critical Medicines

Medicine doses may be frequently omitted or delayed in hospital for a variety of reasons. Whilst only a small percentage of these occurrences may cause harm, for a particular group of medicines known as Critical Medicines it is particularly important to recognise that harm can arise from the omission or delay of these. Examples of Critical Medicines include medicines for treating Parkinson’s disease, epilepsy, diabetes and those for preventing or treating blood clots. We knew from clinical incidents recorded on Datix our incident reporting system, that some patients were not receiving doses of Critical Medicines. What did we say we would do? In 2013/14 we decided to focus on two particular groups of critical medicines: • regular intravenous antimicrobial medication and • medicines for Parkinson’s Disease We said we would undertake an initial audit in April 2013 of prescribed doses of these Critical Medicines that had not been administered, to establish a baseline for improvement in the coming year. Based on our initial audit results we said we would set an ambitious target to reduce the percentage of omitted doses of Critical Medicines by March 2014. Did we achieve this? The initial audit showed that 11% of patients that had been prescribed a Critical Medicine had doses omitted. This was due to several reasons including the availability of the medicine and poor documentation of reason for non‐administration. We set out to improve this figure by 50% by March 2014. Monthly audits have shown that we have achieved this target as illustrated in the graph below, and the percentage of patients in these categories who have omitted doses of medicines for March is 2.5%.

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How did we achieve it? We achieved this by ensuring: • Ward stock lists for key wards where Parkinson’s patients were likely to be cared for were reviewed

and changed to ensure that they had continual stock of Parkinson medicines. • The emergency drug cupboard stock was also reviewed to ensure that Critical Antibiotics were

readily available outside of pharmacy opening hours. • All wards were provided with information on critical medicines and the wards where they are

normally stocked to enable clinical staff to access these out of pharmacy opening hours. Information was also provided on which medicines are stocked in the emergency drug cupboard.

• The Parkinson nurses developed training sessions for ward staff to raise awareness of the importance of giving patients their medication at the prescribed times, and to increase their knowledge and understanding of the different formulations and types of medicines available. Posters and screensavers are to be developed to support these awareness sessions.

• An audit to show why doses of intravenous antibiotic were missed identified the lack of venous access in some patients and poor documentation of reasons for non‐administration were contributing factors. A campaign to raise awareness of these issues was implemented with sessions being delivered at mandatory training and Foundation Doctor training.

• Re‐audit of patients prescribed Parkinson’s medicines and I.V antimicrobials within the previous 72 hours was undertaken monthly and became part of the NHS Safety Thermometer survey to inform if improvement was being achieved.

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Priority 5 Infection Prevention and Control: prevent avoidable healthcare associated infection (HCAI)

The Trust continues to fully support initiatives to reduce all avoidable infection. Some infections are difficult to prevent or in some cases the patient may have entered the hospital carrying the infection. We plan to continue to strengthen our preventative measures in 2014/15 to assure our patients and their families that every effort has been made to keep them or their loved ones safe. Ensuring preventative measures and reducing infection is very important to the quality of patient care. Whilst infections are monitored and followed up for patients during their stay, some key infection results such as Meticillin‐resistant Staphylococcus aureus (MRSA) and Clostridium difficile Infection (CDI) are used nationally to benchmark and measure performance. Healthcare associated infections (HCAIs) are infections acquired as a result of healthcare interventions. Clostridium difficile (C.difficile) and MRSA bacteremia are the most common. C.difficile is a type of bacterial infection that can affect the digestive system, causing diarrhoea, fever and painful abdominal cramps and sometimes more serious complications. The bacteria does not normally affect healthy people, but because some antibiotics remove the 'good bacteria' in the gut that protect against C.difficile, people on these antibiotics are at greater risk. The MRSA bacteria is often carried on the skin and inside the nose and throat. It is a particular problem in hospitals because if it gets into a break in the skin it can cause serious infections and blood poisoning. It is also more difficult to treat than other bacterial infections as it is resistant to a number of widely‐used antibiotics. What did we say we would do? As a Trust in order to strengthen our zero tolerance approach and reduce HCAI’s even further we said we would:‐ 1. Support a reduction in CDI and other reportable infections such as MRSA, Meticillin sensitive

Staphylococcus aureus (MSSA) and Escherichia coli bacteraemia (E. coli). 2. Develop a hand hygiene campaign to demonstrate good hand washing technique for staff, patients

and visitors. 3. Review and update our Trust infection prevention and control patient information leaflets and

guidance for staff. 4. Involve patients in inspecting ward and the hospital environment to ensure it is clean, safe and tidy. 5. Ensure post infection reviews (PIR) and root cause analysis (RCA) takes place in a timely manner

with appropriate learning. 6. Work closely with our community colleagues to develop more robust ways of identifying patients at

risk. 7. Develop an education programme to ensure consistency around Infection prevention and control

messages.

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1. Support a reduction in CDI’s and other reportable infections such as MRSA, MSSA

and E. coli Did we achieve it? Yes we did In 2013/14 the Trust had one case of MRSA bacteraemia however; this was as the result of a contaminated specimen not an infection. We had 20 cases of C.difficile, four cases of the C.difficile were deemed as being unavoidable by an expert appeals panel. This meant that the Trust had a total of 16 avoidable cases of C.difficile against a trajectory of 17. The table below demonstrates how the Trust has made a significant reduction in the incidence of CDI’s since 2007.

2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 Clostridium Difficile Infections Post 72 hours

197 107 105 48 27 22 16

However, as published data demonstrates, the rate of improvement nationally has slowed over recent years. Infection prevention and control experts from within the NHS and from Public Health England advise that this is likely to be due to a combination of factors including the biology and epidemiology of the Clostridium Difficile organism. How did we achieve it? The Trust is proactive with a zero tolerance approach to all avoidable HCAI with a strong focus on prevention and reduction. This is demonstrated by the Trust reporting some of the lowest rates of blood stream infections (bacteraemia) in the region. We have begun to introduce Aseptic Non‐Touch Technique stations (ANTT) to clinical areas to strengthen clinical practice and further reduce the possibility of avoidable blood stream infections. The ANTT station provides a dedicated space for medical and nursing staff to prepare intravenous medication, blood sampling and other high risk procedures within a dedicated clean environment. The Trust is proactive with a zero tolerance approach to all HCAI and work continues to focus on prevention and reduction: • The Trust is currently working closely with the HCAI Reduction Partnership with Newcastle and

Gateshead Alliance and has representation on its Task and Finish Group. • CDI multidisciplinary clinical review meetings take place twice weekly to review current in‐patients,

antimicrobial procedures, treatment, quality of care, records, policy and reporting. • A monthly CDI meeting has been established for clinical staff to review case management, discuss

new ways of working, feedback performance and engage staff through education and learning. • Any positive specimen is reported immediately to the IPCT and followed up to ensure best practice

has been initiated with no exceptions. • A RCA and PIR are held within seven days of any positive specimen reported to identify any lessons

learned with feedback to staff. • The Diarrhoea Assessment and Management Pathway (DAMP) has been introduced to all clinical

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3. Review and update our Trust infection prevention and control patient information

leaflets and guidance for staff. Did we achieve it? Yes we did How did we achieve it? As part of our hand hygiene campaign the Trust hand hygiene information leaflet has been reviewed by staff and patients and updated to ensure it provides clear and up to date information for staff, patients and visitors. Other patient information leaflets related to infection prevention and control are also being updated. 4. Involve patients in inspecting wards and the hospital environment to ensure it is

clean, safe and tidy. Did we achieve it? Yes we did How did we achieve it? Weekly Patient Led Assessments of the Care Environment (PLACE) are undertaken in the Trust. These patient led inspections assess the cleanliness, condition and appearance of the clinical areas and also involve aspects of reviewing hand hygiene such as whether hand cleansers are available. In addition our 15 Steps Challenge visits that involve patients also incorporates the following prompts for the team: • A clean environment • Hand gels are available and used • Clear information about infection control • Rubbish / dirty items and linen disposed of appropriately and not visible We will continue to involve patients in this important improvement work. 5. Ensure Post Infection Reviews and Root Cause Analysis takes place in a timely

manner with appropriate learning. Did we achieve it? Yes we did How did we achieve it? All cases of post 72 hour CDI are investigated and an RCA is undertaken usually within a seven day period. The case is discussed to determine any deviations from expected practice and identify any learning to improve patient care. During November the Trust reported one MRSA bacteraemia case. A review was conducted involving a multidisciplinary team with representation from our Clinical Commissioning Group. Learning was identified as part of the process and communicated to the relevant personnel. The review concluded that the MRSA bacteraemia was actually a contaminant. This means that the sample of blood had become contaminated during the blood taking process rather than the patient actually having an MRSA blood infection. The Trust continues to report the lowest MRSA bacteraemia data in the region.

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6. Work closely with our community colleagues to develop more robust ways of identifying patients at risk

Did we achieve it? Yes we did How did we achieve it? In strengthening the culture of partnership working across the North East region our Infection Prevention and Control team (IPCT) work with other IPC teams across community especially when investigating infection outbreaks and individual cases of HCAI. The IPCT and community colleagues are currently reviewing the way information about HCAI and other infections is shared to improve communication and better patient outcomes relating to appropriate advice and treatment. 7. Develop an education programme to ensure consistency around Infection

prevention and control messages. Did we achieve it? Yes we did How did we achieve it? Education, training and development continues to be a key area of development ensuring all staff are provided with appropriate mandatory training as well as opportunities for further development for infection prevention and control. Education continues to be delivered through the mandatory training requirements of the Trust for both clinical and non‐clinical staff. Targeted education and training is provided to individual clinical areas and staff when incidents have occurred or simply when it is required as recognition of personal development. The education, learning and development for infection prevention and control will be further strengthened through the development of a Trust Infection Prevention Academy.

The Infection Prevention Academy

Vision is to be a centre of excellence and beacon of best practice for infection prevention development, education, training and development. Mission is to develop outstanding infection prevention leadership, competence, knowledge, understanding, attitudes and skills for the prevention and control and improved quality of care. Core values to ‘BREDE’ the following within our staff: Broaden & change behaviours with regard to infection prevention. Raise the profile, performance & impact of prevention and control. Engage and strengthen partnership working. Develop innovation. Expectations to improve patient care through up to date knowledge, experience and engagement to reduce HCAI.

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I have really enjoyed taking part in the 15 step challenge visits. They are a great way of supporting the Trust to view their services from a patient’s perspective Pat Green (Patient Volunteer)

Patient Experience

Priority 6 Implement the 15 Steps Challenge

Getting an insight into patients' perspectives is vital if we are to improve their experience of care. Understanding how patients feel about the care they receive can only truly be achieved by looking through their eyes. Both patients and staff have high expectations for safe, good quality care, delivered in welcoming and clean environments. A good first impression builds patient confidence and reassurance. What did we say we would do? We said we would implement ‘The 15 Steps Challenge’, developed by the NHS Institute for Innovation and Improvement. This is a tool to help staff, patients and others to work together to identify improvements that will enhance the patient experience. The 15 Steps Challenge is a ward walk around, seeing the ward through a patient’s eyes. A small team consisting of a patient or carer, a staff member and a board member or governor walk onto the ward or department and take note of their first impressions. After the walk around, the 15 Steps Challenge Team feedback both the positive findings and the key areas for improvement to the ward or departmental team. The 15 Steps Challenge is repeated on a regular basis, to cover all ward areas and departments and to ensure that improvements are being progressed. Did we achieve this? Yes we did How did we achieve it? • We identified a Trust sponsor who has ensured that the 15 Steps Challenge is aligned to strategic

priorities for the trust and who has supported the Board to Ward involvement. • We launched the initiative at our Nursing and Midwifery conference in May 2013 as well as raising

awareness with staff, patients and visitors across the organisation through a variety of methods including posters, bulletins, forums and education sessions.

• We then recruited and trained a pool of 15 steps challenge team members consisting of a wide range of staff, patient, carers and non‐executive board members. Over time, having a pool of people will ensure that the visits and time commitment are shared by many people and not just a few. It will also ensure that the pool of “fresh eyes” is enhanced, and different people can undertake review visits, rather than the same 15 Steps Challenge team members making repeat visits.

• We decided to take an incremental approach to the implementation of the 15 steps challenge visits, to learn how we could improve our approach to each visit and have now undertaken 12 visits this year.

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What have the visits highlighted?

Positives

• Friendly helpful staff • Clean and safe environment • Hand gels available throughout the ward • Staff identification badges clearly displayed • Patient comments about care very positive • Call bells within easy reach of patients • A calm and organised ward • Patient buzzers answered quickly

Recommendations

• Information for patients to help identify what the different colours of staff uniform mean

• Clearer visiting time signage • Better organisation of information boards

We will continue to develop this work throughout the coming year.

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2.2 Our Quality Priorities for Improvement in 2014/15 Our new SafeCare Strategy 2014/17 aims to deliver a programme of work that will reduce harm and avoidable mortality, improve our patients experience and make the care that we give to our patients reliable and grounded in the foundations of evidence based care. This is complimented by our new Patient Experience and Involvement Strategy framed on the concept of five Steps to Excellent Care. We have set six key priorities for quality improvement for 2014/15 and these are linked to patient safety, effectiveness of care and patient experience. We have established our priorities for improvement in 2014/15 through the following: • Consultation with our staff through a variety of established forums and meetings. • Governor engagement • Discussions with our Patient Panel, Carers Group and Patient, Carer and Public Involvement Group • Discussions with commissioners and alignment to our CQUIN scheme • SafeCare plans and identified priorities of our clinical services • Internal and external data sources and reports including: Care Quality Commission standards,

recommendations from national reviews into the quality and safety of patient care within the NHS, local and external clinical audits and analysis of complaints and incident reports.

• Progress against existing quality improvement priorities • Alignment with our SafeCare Strategy 2014/17 and Trust objectives Following Trust Board consideration of our analysis our six priority areas for quality improvement are: Priority 1: Continue to focus on reducing avoidable deaths in hospital Priority 2: Continue to improve the care of patients living with a diagnosis of Dementia and creating a

Dementia friendly hospital Priority 3: Reduce inpatient falls that cause harm to patients Priority 4: Continue to reduce omitted doses of critical medicines Priority 5: Implement ‘Open and Honest Care: Driving Improvement ’ Priority 6: Continue to embed the 15 Steps Challenge Last years’ priorities of Infection Prevention and Control and Reducing Avoidable Readmissions to Hospital will remain an area of high importance for the Trust and this work is embedded in our quality improvement and reporting framework. We will continue to drive and monitor progress in these key areas. Our Governors and Board of Directors are particularly keen to ensure that progress is maintained.

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Priority 1: Continue to focus on reducing avoidable deaths in hospital

What will we do? We will aim to achieve a year on year reduction in mortality utilising the crude mortality rate, the Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital‐level Mortality Indicator (SHMI). Our aim is to achieve lower than expected or as expected SHMI banding and by the end of 2015 achieve a SHMI of 0.99 or below. How will we do it? We will continue to implement our mortality reduction strategy which will guide the organisation on the next phase of its work in reducing avoidable mortality over the next three years. We will continue to focus on three primary areas for change recognised to be important to reducing mortality: • Leadership • Clinical Care • Documentation & Informatics

Leadership at all levels is vital in creating a culture in which patient safety and quality improvements can be made and sustained. Strong clinical leaders are essential in ensuring that the vision is communicated and understood across all clinical areas and that the concerns of frontline staff are escalated upwards to drive innovation. • We will continually review our mortality governance arrangements, from ward to the board, to

ensure these are embedded throughout the organisation. • We will continually review the provision of information and data the Board receives related to

mortality to ensure its usefulness in informing decision making. • Board members will understand adjusted mortality ratios and regularly engage with front line staff

to monitor and facilitate changes in practice. • We will examine the findings of our Patient Safety Culture Assessment that captures key

components of team work, openness, involvement of junior staff and willingness to change. This will help us to better understand and make changes in our safety culture where necessary.

• We will continue to work collaboratively with other Trusts in the region to share and implement learning where possible.

Clinical Care To deliver care that is safer, more effective, and that provides a better experience for patients we will: • Continue to strengthen our processes related to review of deaths across the Trust to ensure that all

services are included and that feedback and emergent learning is shared through business unit assurance structures and the Mortality and Morbidity Steering Group.

• Based on our review of deaths the Mortality and Morbidity Steering Group will set clinical priorities and commission reviews of clinical care where there is potential for improvement. In 2014/15 we will focus on : • Early recognition of Sepsis, otherwise known as septicaemia or blood poisoning • Care of the frail and elderly • Hydration and fluid management

• Where appropriate we will take a clinical care bundle / clinical pathways approach for particular conditions as a basis for improving care.

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• With the aim of improving patient access to clinical services we will continue our work on reviewing which services can be extended to be delivered seven days a week in a sustainable way.

• We will review our working practices to ensure that appropriate senior and junior medical support is available to wards and departments out of hours.

Effective and Safe Handover • We will continue our work on reviewing our processes for clinical handover of patients to ensure

that we have standardised systems in place that assure our patients are safe, diagnosed efficiently and treated effectively.

• We will include clinical handover and communication of care in staff training and induction. • We will develop pragmatic and ‘lean’ systems to monitor our standards of clinical handover. Documentation & Informatics Clinical documentation must be complete and accurate to support clinical care and to enable the coding of hospital episodes. Coding translates care into data that drives revenue and many hospital statistics, including adjusted mortality data. Whilst we have undertaken considerable work to better understand the complexities of clinical documentation and coding we will continue to strengthen and develop this work. • We will continue to regularly review hospital performance of HSMR, SHMI, crude mortality rates

and diagnosis specific rates as part of a suite of general quality improvement measures. • We will support our staff in interpreting mortality data and identifying areas for review. • We will continue to utilise the services of the North East Quality Observatory (NEQOS), accessing

information and data available for benchmarking via the quarterly reports and identifying any areas of work data analysis that they may undertake with or on our behalf.

• We will explore various ways of working that encourages partnership between clinicians and coders and enables continuous improvement of documentation and coding. A key focus will be to ensure that the order of coding is correct and that the primary diagnosis is definitive and reflective of the patient’s condition.

• We will continue to implement a programme of education and training for clinical staff in relation to clinical documentation and its translation to coding.

• We will regularly monitor and review our palliative care coding trends. How will we measure it? We will continue to use the crude mortality, the HSMR and the national measure SHMI. How will we monitor and report it? We will monitor and report progress: • Monthly to the Board through the Quality & Safety Dashboard and a quarterly detailed report • Monthly to the Mortality and Morbidity Steering Group • Monthly divisional reports for consultants and clinical leads with benchmarked performance • Twice a year to the Patient Quality Risk and Safety Committee (PQRS)

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Priority 2: Continue to improve the care of patients living with a diagnosis of dementia and creating a dementia friendly hospital

One in 14 patients over the age of 65 currently has a diagnosis of dementia – around 850,000 patients in the UK and that is expected to increase to 1.7 million by 2015. Our patients tell us that what they need from us is kindness, compassion, a smile, understanding and most importantly to be their voice when they are unable to speak. In 2014/15 we will continue to progress our work in relation to dementia care through the delivery of our Dementia Strategy overseen by the Dementia Steering Group. What will we do? • Further establish and implement the work programmes of the four newly established dementia

work streams: - Delivering CQUIN indicators that focus on improving dementia and delirium care, including

sustained improvement in: Finding people with dementia, Assessing and Investigating their symptoms and Referring for support (FAIR).

- Education and Training - Dementia Environment - Nutrition

• We will continue our programme of environmental audits within the Queen Elizabeth Hospital • Based on these environmental audits we will further develop our environmental action plan via the

Dementia Environmental work stream • Roll out the ‘Forget me Not’ programme including the use of specific identification bands • ‘Barbara’s Story’ session to be accessed by all staff within the Trust. • Also further develop Level I and II dementia training within Trust • Continue to undertake carers and users satisfaction survey • Undertake a review of our dementia and delirium care pathways How will we do it? • Using the University of Sterling Dementia Environmental Toolkit we will

audit all wards and departments over the next 12 months. • Produce dementia friendly ward action plans • Identify three levels of Dementia training – basic awareness, intermediate and specialist • ‘Forget me Not’ wristbands will be worn by all patients with dementia • Undertaken a number of Dementia road shows within the Trust • Dementia friendly signage will be erected throughout the Trust • Hold a market stall at Share and Learn Day • Further launches regarding ‘Forget me Not’ in public access areas • Develop screensavers • Forget Me Not flowers for patient boards on wards How will we measure it? • Environmental audit of all Wards and Departments • Undertake an evaluation of ‘Forget me Not’ wristbands • Staff attendance at training programmes • Evaluation of Dementia road shows • Feedback from carers questionnaires • Performance against CQUIN measures

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How will we monitor and report it? • Monthly Dementia Steering Group • Monthly Quality Outcomes Meeting • Monthly Board to Board Performance Meeting • Quarterly Mental Health Act Committee

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How will we measure it? We will measure our compliance with the key aspects of care: • Post falls bundle • In depth assessment and plan of care • The four basics We will report all falls through Datix, our incident reporting system to enable us to measure the number and rate of all falls per 1,000 bed days as well as harmful falls per 1,000 bed days How will we monitor and report it? We will monitor and report progress: • Monthly to the strategic falls group • Twice a year to SafeCare Council • Twice a year to the Board of Directors • At Governors workshops and events

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Priority 4: Continue to reduce omitted doses of ‘Critical Medicines’

We made excellent progress in 2013/14 achieving our target and reducing the number of missed doses of I.V antimicrobials and Parkinson’s medication by more than 50%. However, we are aware from audits undertaken as part of the ward Safety Thermometer that some doses of critical medicines continue to be missed. We will therefore continue to focus on this important aspect of patient safety. What will we do? • We will continue to measure the number of missed doses of I.V Antimicrobials and Parkinson’s

medication to ensure we sustain the improvements made in 2013/14 and where possible further improve on this.

• In addition we will:

• Focus on improving missed doses of Tinzaparin. Tinzaparin is an anti‐clotting medicine given by injection to help prevent the development of deep vein thrombosis (when a clot forms in a deep vein within the leg) or pulmonary embolism (a blood clot that has come away from its original site and becomes lodged in one of the lungs). Whilst currently 95% of patients receive their prescribed doses of this medicine we aim to further improve on this in 2014/15 to at least 98% by March 2015.

• Focus on ensuring that patients in our care receive their Insulin on time. Insulin is a

hormone that is an important part of diabetes treatment. The main job of insulin is to keep the level of sugar in the bloodstream within a normal range. Our medication storage audits show us that insulin is often not stored appropriately, ordered in excess leading to waste, and is not always immediately available for the patient when required.

We will: 1. Increase the use of patients own supply of Insulin. 2. Improve the storage of Insulin in ward areas 3. Improve the timeliness of administration of Insulin 4. Reduce the amount of insulin wasted due to excessive ordering

How will we do it? • We will continue to audit the number of missed doses of I.V anti‐microbial and Parkinson’s

medicines to ensure the excellent improvements seen in 2013‐14 are maintained and improved upon.

• We will continue to raise awareness of staff through the development of screen savers, and posters to ensure continued adherence to the standard throughout 2014/15.

• We will target the areas where most doses of these critical medicines are missed by holding focus groups and education sessions.

• A baseline audit will be undertaken to assess o Whether diabetic patients have brought their own insulin into hospital o How many diabetic patients are using or being given their own insulin o If the insulin is being stored appropriately and is accessible o Excessive ordering and levels of waste

• We will encourage diabetic patients to bring their insulin into hospital with them

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How will we measure it? • We will undertake a programme of clinical audits to measure the percentage of missed prescribed

doses that have not been administered of Critical Medicines across the organisation. • We will measure storage of insulin against the standards set for secure storage of medication and

guidelines for insulin storage. • We will measure the percentage of patients with their own Insulin. • We will ask patients if they were administered their insulin when they required it, and ask them for

improvement ideas. How will we monitor and report it? We will monitor and report progress: • Quarterly to the Medicines Governance Group • Twice a year to SafeCare Council • Twice a year to the Board of Directors • At Governors workshops and event

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Priority 5: Implement ‘Open and Honest Care: Driving Improvement ’

The NHS is on a journey of openness and transparency. We know that there is a strong link between excellent healthcare and an excellent reporting culture where issues are flagged up early and discussed openly so lessons can be learnt and improvements put in place. It is also important that members of the public are able to access key information about their local health services. The Trust is committed to making more information available about the quality of our care. Open and Honest Care: Driving Improvement is a national initiative and a central part of NHS England’s ambition to ensure every patient gets high‐quality care, and to build improved services for the future. It was piloted in the North West in 2010 with eight Trusts publishing information on their websites on falls and pressure ulcers reported in their Trusts, alongside commentary describing the improvements being made to care delivery. It is part of the key actions of the Nursing Strategy: Compassion in Practice that sets out to support organisations to become more transparent and consistent in publishing safety, effectiveness and experience data; with the overall aim of driving improvements in practice and culture. What will we do? We have made a commitment to publish a set of patient outcomes; patient experience and staff experience measures so that patients and the public can see how we are performing in these areas. How will we do it? Every month we will publish our ‘Open and Honest’ report via the Trust internet site http://www.qegateshead.nhs.uk/openandhonestcare and NHS Choices. The information will include the following: • NHS Safety Thermometer

On one day each month we check to see how many of our patients suffered certain types of harm whilst in our care. We call this the Safety Thermometer. The Safety Thermometer looks at four harms: pressure ulcers, falls, blood clots and urine infections for those patients who have a urinary catheter in place. This helps us to understand where we need to make improvements. We will publish a score to show the percentage of patients who did not experience any new harm.

• Information on healthcare associated infection, (MRSA and C Diff)

As discussed earlier, we have a zero tolerance policy to infections and are working towards eradicating them; part of this process is to set improvement targets. If the number of actual cases is greater than the target then we have not improved enough. We will publish the number of MRSA and C. difficile infections we have had each month plus the improvement targets and results for the year to date.

• Pressure ulcers Pressure ulcers are localised injuries to the skin and/or underlying tissue as a result of pressure. They are sometimes known as bedsores. They can be classified into four grades, with one being the least severe and four being the most severe. Each month we will publish the number of pressure ulcers graded 2‐4 that were acquired during hospital stays. So we can know if we are improving even if the number of patients we are caring for goes up or down, we also calculate an average called 'rate per 1,000 occupied bed days'. This allows us

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to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report pressure ulcers in different ways, and their patients may be more or less vulnerable to developing pressure ulcers than our patients. For example, other hospitals may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses. Each month we will report our rate of pressure ulcers grade two‐four per 1,000 occupies bed days.

• Falls causing moderate or greater harm

This measure includes all falls in the hospital that resulted in injury, categorised as moderate, severe or death, regardless of cause. As with pressure ulcers we also calculate an average called 'rate per 1,000 occupied bed days' for falls. Again this allows us to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report falls in different ways, and their patients may be more or less vulnerable to falling than our patients. For example, other hospitals may have younger or older patient populations, who are more or less mobile, or are undergoing treatment for different illnesses. Each month we will report our rate of falls categorised as moderate, severe or death per 1,000 occupied bed days.

• Information on staff experience Every month we ask our ward teams e.g. nurses, doctors, domestics, housekeepers, porters, physiotherapists, dieticians and pharmacists the following three questions: • I would recommend this ward/unit as a place to work • I would recommend the standard of care on this ward/unit to a friend or relative if

they needed treatment • I am satisfied with the quality of care I give to patients, carers and their families

Staff will choose from the following responses for each question: • Strongly agree • Agree • Neither agree nor disagree • Disagree • Strongly disagree Each month we will publish our Trust level results.

• Information on patient experience including Friends and Family Test

The Friends and Family Test is a single question survey which asks patients after discharge from wards and A&E whether they would recommend the service they have received to friends and family who need similar treatment or care. It also uses a net promoter score. We will publish the Trust level results of our monthly in patient survey and the number of patients who have responded. We will publish our monthly hospital (combined inpatient and A&E) NET promoter score and the number of patients who have responded.

• A patient story Each month we will publish a patient story with the purpose of seeing care through the eyes of the patient or family member and told in their own words. The story will be used to share positive experiences or those where improvement needs to be made.

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• An improvement story

This will describe what the trust has learnt from reviewing the quality of our services and what improvements we are making.

How will we measure it? We will submit our data to NHS England within the set timescales each month. We will upload our completed reports to the Trust internet website each month and the reports will be available via NHS Choices. How will we monitor and report it? We will monitor and review progress: • Quarterly to Nursing and Midwifery Professional Forum • Twice a year to SafeCare Council • Twice a year to the Board of Directors • At Governors workshops and event This information is being published as part of this open approach and to encourage quality improvements. We will work with our partners such as other health care providers, commissioners, local authorities, Health Watch and primary care to make relevant improvements to the quality of care and openly report progress and outcomes. However, it is important to note that the information in these reports cannot be used in isolation to make comparisons about the safety or quality of healthcare at different organisations. Differences in the ways that organisations collect data and the patients that they care for, and the services they provide, all mean that direct comparisons are not possible.

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2.3 Statements of Assurance from the Board During 2013/14 the Gateshead Health NHS Foundation Trust provided and/or sub‐contracted 32 relevant health services. The Gateshead Health NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by the relevant health services reviewed in 2013/14 represents 100% per cent of the total income generated from the provision of relevant health services by Gateshead Health NHS Foundation Trust for 2013/14. Participation in clinical audit During 2013/14, 31 national clinical audits and five national confidential enquiries covered relevant health services that Gateshead Health NHS Foundation Trust provides. During that period Gateshead Health NHS Foundation Trust participated in 94% national clinical audits and 100% national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that Gateshead Health NHS Foundation Trust was eligible to participate in during 2013/14 are listed in Appendix 1. This also gives details of the National Audits that the Trust was not eligible to take part in. The national clinical audits and national confidential enquiries that Gateshead Health NHS Foundation Trust participated in during 2013/14 are listed in Appendix 1. The national clinical audits and national confidential enquiries that Gateshead Health NHS Foundation Trust participated in, and for which data collection was completed, during 2013/14, are listed in Appendix 1 alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registration cases required by the terms of that audit of enquiry. The Trust utilises Clinical Audit as a process to embed clinical quality at all levels in the organisation and create a culture that is committed to learning and continuous organisational development. Learning from Clinical Audit activity is shared throughout the organisation from Ward to the Board. The reports of 18 national clinical audits were reviewed by the provider in 2013/14 and Gateshead Health NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:

National Clinical Audit Priority for ImprovementNational Potential Donor Audit

The Trust’s overall performance was very good, and we were above the national average for referral to Specialist Nurse for Organ Donation (SNOD) for both Donors after Brain Death (DBD) and Donors after Cardio‐respiratory Death (DCD), approach rate for DBD and DCD, consent rate of DBD and DCD, actual donors both DBD and DCD and families approached with SNOD national average for DCD. However there was one area highlighted for improvement in relation to increasing the involvement of the SNOD when approaching DBD. The following action has been identified:‐ Actions: • Programme of education to be developed for staff in critical care and emergency

department to raise awareness of the importance and the involvement of the SNOD. This will include study days, presentation of audit results, consent training, use of a DVD and reference to National Guidelines.

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National Clinical Audit Priority for ImprovementNational Paediatric Asthma Audit

The department performed very well in initial assessment, care given followed British Thoracic Society’s Guidelines, initial Bronchodilator (medicines that are used to treat breathing problems in people with asthma) taken with spacer (a large plastic or metal container, with a mouthpiece at one end and a hole for the aerosol inhaler at the other, spacers are important because they help to deliver asthma medicine to your lungs) in 100% of patients, appropriate use of oxygen and nebulisers. However areas for improvement identified were prescription of steroid within one hour of admission, discharge planning and follow up information. The following actions have been identified to order improve these elements of the service. Actions: • Clinical guidelines to be developed for use in the Paediatric Emergency

Assessment Pod. • Generic discharge proforma to be developed and implemented. • Follow up clinics to be implemented.

College of Emergency Medicine ‐ National Renal Colic Audit 2012

The Accident and Emergency Department improved on the 2010 audit on the recording of initial pain scores and documentation. The results of the audit did identify areas for improvement in pain scoring re‐assessment, documentation around results particularly renal function and full blood count and reducing the length of stay in the department. Actions: • Programme of education to be developed for staff within the Emergency

Department in relation to pain management and re‐evaluation and documentation of results for renal colic patients.

College of Emergency Medicine – Fractured Neck of Femur 2012

The Accident and Emergency Department’s overall performance was very good with patients receiving analgesia quickly and in accordance with need. 98% of pain scores were recorded. 62% of patients had their analgesia re‐evaluated. 92% of patients were admitted within four hours. However there are areas for improvement and by implementing the following actions the quality of care will improve:‐ Actions: • In collaboration with the Trauma Co‐ordinator, develop a programme of

education to re‐energise the fast track pathway for fractured neck of femur. • In order to improve delays in transferring patients from Accident & Emergency to

X‐ray, explore the possibility of having an allocated porter for the Accident & Emergency department.

• Develop a programme of education in relation to re‐evaluation of pain.

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National Clinical Audit Priority for ImprovementNational Diabetes Inpatient Audit 2013

The results of the audit identified good practice in relation to appropriate blood glucose monitoring and good diabetes control 66.7% patients admitted with foot disease were seen within 24 hours by the multidisciplinary team (compliance with this standard in 2011 was 0%). Reduction in medication and insulin management errors from previous year reduce to 36.4% from 45%. The audit result have identified areas requiring improvement specifically; number of medication errors, insulin management errors and foot risk assessment during admissions. The following actions have been identified:‐ Actions: • E‐learning package and bite size education sessions have been developed for staff

prescribing or administering insulin. • An introduction to diabetes and advanced diabetes care study days have been

developed in conjunction with the OD and Training Department. • A Care Pathway and weekly foot assessment tool have been developed for

patients admitted with diabetic foot ulcers. A programme of education has been developed to support the implementation of the new pathway and assessment tool.

National Cancer Patient Survey

We are extremely proud to report we were the best performing Trust in this year’s National Cancer Patient Survey. The Trust’s overall performance was excellent achieving scores rated in the top 20% of Trusts nationally for the majority of questions asked. We have maintained a strong position in the top 5 performing Trusts nationally for the past three years. It is recognised that the contribution of all staff who can or will affect the important cancer journey for patients do make a difference to that experience. However there are still areas which we will strive to improve. The following action have been identified:‐ Actions: • Improve written information by re launching the patient hand held information

booklet with user involvement. • Formalise and roll out Holistic Assessment in all site specific tumour groups. • Improve patient access to Macmillan Cancer Information Centre that will also

improve benefits advice for appropriate patients. • To readdress information given to patient in relation to clinical trials/research

that will improve appropriate discussions with patients regarding taking part in cancer research and trials.

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National Clinical Audit Priority for ImprovementNational Diabetes Audit – Paediatrics

As well as the day‐to‐day blood glucose testing, there is another test that monitors children’s diabetes management. The HbA1c test (usually done from a fingertip blood test, this measures diabetes management over two to three months). The results demonstrated that 50% of children and young people attending the QE Gateshead Diabetes Service have an HbA1C level above 75.5mmol/mol, the target HbA1C is less than 58mmol/mol. The following actions have been identified. Actions: • Policy to deal with high HbA1C particularly in the teenage/ transition age group

to be developed in line with regional and national recommendations. • Continue to provide education to staff of the need to ensure all foot care

processes are recorded on the clinical data system. • Lipid screening is now routinely offered in transition clinic over 16yrs. • Work with the Coding Department to ensure accurate coding processes are

developed for diabetes admissions. • Reduce hospital admissions for children and young people with diabetes by

providing increased Paediatric Diabetes Specialist Nurse & dietetic support and structured education in addition to the availability of 24 hour medical advice from senior clinician on the diabetes team for all children and young people under 19 years.

• Continue to raise awareness to increase recognition and diagnosis of Type 1 Diabetes in primary care (4T’s campaign). Letters sent to all GP practices + paediatric diabetes on primary care diabetes education programme and active engagement in primary care diabetes development forum.

• Develop a business plan to ensure resources are available through the trust as commissioned in keeping with national best practice tariff.

Severe Trauma Audit & Research Network (TARN)

The Accident and Emergency Department’s overall performance was very good. The median time to CT scan has improved from 1.3 hours in 2011/12 to 0.8 hours in 2012/13. The data completeness for the audit has also improved from 66% to 77%. The results however did identify areas for improvement, particularly in relation to documentation. The following actions have been identified in order to improve the quality of our Accident & Emergency Service:‐ Actions: • Improve data completeness to 80% by ensuring that the member of staff

identified to input the data has the protected time to do this. Also undertake some further work to ensure that all patients eligible to be included in the audit are identified.

• Include information on the TARN system on patients who have been transferred to and from the Accident & Emergency Department to the Major Trauma Centre.

• Improve trauma call activation recording and input by developing a new trauma document for use in major trauma patients.

National Heart Failure Audit

The results demonstrated a marked improvement from the previous year and the Trust’s performance is above the national average on most of the indicators/measurements. One area was identified as below average, in relation to outpatient consultant review post discharge; however we do not routinely offer this type of appointment to every patient but do offer it to those patients where it is felt appropriate. There are no actions required.

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National Clinical Audit Priority for ImprovementNational Comparative Audit ‐ The Medical use of Blood ‐ Part 2

This was a two part audit. 37 blood transfusions were submitted to the first part, out of these 11 were selected for further investigation in the second part. The audit identified that the majority of the transfusion practice was appropriate and reflected the high quality of care given. However, based on the review of the 11 cases, 5% of patients with reversible anaemia and 8% of patients transfused above the Haemaglobin (the protein in your red blood cells that carries oxygen) threshold were considered to be inappropriately transfused. The following actions have been identified in order to improve practice further: Actions: • Tools to be developed by the NHS Blood Transfusion Service to support the

recognition, investigation and management of anaemia. • Simple clinical guidelines to be developed by the NHS Blood Transfusion Service

to support blood transfusion decision making. • Awareness raising and education for staff around the importance of documenting

the reason for blood transfusion and gaining patient consent for blood transfusion.

SSNAP This is a national audit of stroke patient care in England. The data is collected prospectively about the patients admission and hospital stay until their discharge. Due to the nature of stroke care, this involves a number of specialties working in harmony. There are areas of good practice at QE Gateshead, in that stroke patients appear to be admitted quickly to a stroke unit and have access to specialist assessments promptly. The following actions for improvement have been identified. Actions: • Develop seven day working in therapy services in line with national standards. • Develop action plan to improvement joint health and social care planning,

assessment of mood and cognition • Continue to implement staff training to improve swallow assessment and

management in order to improve nutritional standards. • Commence the use of compression stockings for Venous Thromboembolism

(VTE) management in line with NICE guidance.

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National Clinical Audit Priority for ImprovementMyocardial Ischaemia National Audit Programme (MINAP)

The Myocardial Ischaemia National Audit Project (MINAP) examines the quality of management of heart attacks (myocardial infarction) in hospitals in England and Wales. The audit enables hospitals to measure their performance against targets in the national service framework to monitor and improve the care of heart attack patients. In addition, it now allows hospitals to monitor the care of all acute coronary syndromes (ACS) patients. Whilst the Trust either improved or maintained its previous performance across the keys standards. One area that the published audit data highlighted was a significant decline in the proportion of patients that received all the secondary prevention medications for which they were eligible from 72.4% in 2011/12 to 48.3% in 2012/13. However it is of note that this was not an accurate reflection of the clinical reality due to data quality issues. Actual performance was in the range of 80% and we are working with National Institute for Clinical Outcomes Research to rectify these issues and the data has been resubmitted. Actions: • Ensure consistency of input of information into the cardiology database by

weekly review of dataset via electronic patient administration system in collaboration with the Information Department.

• Further training and development of the role of the Chest Pain Nurse to ensure high standard of review within the Accident & Emergency Department, in order to ensure smooth flow of patients from the Accident & Emergency Department to base wards/discharge home. Also Chest Pain Nurse to continue to support ward areas in the care of cardiology patients and whenever possible ensure that the care is provided within the cardiology ward.

• Amend the induction programme for new members of the team, so that this now includes a section on the importance of inputting data into the MINAP database.

National Cardiac Arrest Audit

The interim results have so far demonstrated the proportion of cardiac arrests per 1000 hospital admissions are lower than the national average. However the presenting rhythm for cardiac arrests are predominantly non‐shockable which proportionally higher than expected. There are above average proportion of patients suffering cardiac arrest in in the older age groups (75+yrs) and between 1‐7 days following admission. Initial survival from cardiac arrest is within expected range, however survival to discharge remains lower than expected where the presenting rhythm was non‐shockable. The following actions have been identified:‐ Actions: • Promote early decisions relating to resuscitation for all acute admissions by

consultant review. • Continue to Identify factors contributing to cardiac arrests in hospital by

performing retrospective reviews on a proportion of cardiac arrests identifying events in the previous 48 hours

• Develop centralised electronic early warning scoring (VitalPAC) to prompt monitoring of timely patient observations and highlight deteriorating patients early to supporting teams.

• Audit the post arrest period of care following return of spontaneous circulation to identify potential improvements of care.

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National Clinical Audit Priority for ImprovementNational Intermediate Care Audit

The results of the audit demonstrated that overall the compliance was in keeping with national results. It is important to note that when the audit data was submitted the Intermediate Care and Rehabilitation (ICAR) Unit, the unit was newly opened and was not functioning at full capacity. The following areas of good practice were identified; 80% compliance with quality standards, service accessibility 24/7, number of registered nurses and nursing assistants within established compared to national average, lower than average length of stay, patient reported experience measures were largely positive. The results of the audit did identify some areas which could be improved; time of referral to admission, patient experience – being involved in goal planning, aims, decision making and discharge planning, keeping patients better informed. The following actions have been identified:‐ Actions: • Identify a key person for each patient to be the care lead during the patients stay. • Ensure all referrals are processed and admissions arranged in line with the

timeframes within service specification. • Ensure the intermediate care hub has real time ICAR bed status to add to total

bed stock across all bed based services in the city to ensure adequate and timely patient flow to the appropriate service.

• Often summaries/medication lists are not sent when a patient is referred to ICAR from secondary care. Raise awareness with staff that these incidents should be reported consistently via the incident reporting system and fed back appropriately to the hub and the referrer.

• Raise awareness with staff that all patient information should be gathered from the patient at time of admission and any missing information should be clarified at that point. Mandatory field to be added to the electronic patient database in order to monitor whether this has been done.

• All patients to have a planning meeting within two weeks of their stay at ICAR and repeated if necessary. Ensure that goals are agreed with the patient and documented in their therapy plan. Daily Co‐ordinator to ensure staff are actively encouraging and involving patients and offering them the opportunity to have detailed explanation/answers to any questions.

• Ensure that the estimated date of discharge is updated on ticket home board to ensure that the patient is kept informed at all times.

• Continuously monitor patient feedback from various sources i.e. Friends & Family Test, complaints, compliments to identify any themes in relation to the quality and safety of patient care.

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National Clinical Audit Priority for ImprovementNational Audit of Dementia – Round 2

The results of the audit demonstrated good overall compliance particularly in relation to the Mental Health Liaison Service and Dementia Pathway used within the Trust. However improvement could be made in relation to discharge and transfer of patients. Actions: A full robust action plan has been developed and is being implemented in conjunction with the Trust’s Dementia Work Programme and covers the following broad areas: • Governance • Assessment • Discharge Planning and Discharge • Information and Communication • Mental Health Liaison and Psychiatry • Access to Services • Nutrition • Resources supporting people with Dementia • Support for Carers • Training and Support for Staff • Ward Staffing • Physical ward environment

College of Emergency Medicine – Consultant Sign off

The purpose of this audit was to identify current levels of compliance with the College of Emergency Medicine standard, the extent to which these have changed since the 2011 audit and the impact of this standard on current practice, in order to inform subsequent review. The standard specifies that the following patient groups should be reviewed by a consultant in Emergency Medicine (EM) prior to discharge (i.e. discharge home or to their usual place of residence) from the ED: • Adults (over 17 years of age) with non‐traumatic chest pain • Febrile children less than 1 year old • Patients making an unscheduled return to the ED with the same condition within

72 hours of discharge from the ED.

Summary of results 49% of target group patients ‘signed off’ by middle grade doctor or Consultant. 11% of target group patients ‘signed off’ by Consultant The audit is most likely to under‐represent the level of Consultant/ senior doctor clinical input into target groups. (This is likely due to a combination of: inadequate data capture/ recording, the audit not differentiating between CT3 and other junior doctors and the autonomous processing of some chest pain patients by Cardiology Nurse Practitioners. Actions: • Business case for expansion of Consultant staffing currently under consideration

by Trust. • Approval and funding secured for expansion of middle grade tier, however some

posts remain unfilled. • Review of revise the Emergency Department clinical documentation with a view

to increase the capture of Consultant input/review activity.

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National Clinical Audit Priority for ImprovementLung Cancer The National Lung Cancer Audit looks at the care delivered during referral, diagnosis,

treatment and outcomes for people diagnosed with lung cancer and mesothelioma. The 2012 National Lung Cancer Audit data indicates that the Trust has lost its previous position as positive outliers for median survival, active treatment and small cell lung cancer receiving chemotherapy, and we are now negative outliers for non‐small cell lung cancer receiving surgery. Actions: • Carry out detailed examination of data due to concerns regarding data quality

and validity. • Highlight differences between LUCADA data set and clinical reality. • Discuss results in Annual General Meeting regarding changes in quality

management for 2013 data. • Review activity and capacity in light of impact of national campaign.

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Outstanding National Audit Reports to be published in 2014/15 National Bowel Cancer Audit Neonatal Intensive and Special Care National Comparative Audit on the Use of Anti D The reports of 32 local clinical audits were reviewed by the provider in 2013/14 and Gateshead Health NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:

Local Clinical Audit Priority for Improvement

An audit to assess whether North East (NE) Abdominal Aortic Aneurysm (AAA) Vascular Unit Referrals met all key performance indicators 2012 ‐ 2013

This audit identified that NE AAA Screening is performing within acceptable quality standards for referrals. Current performance is 53.8% (standard is 60%) and 76.9% (standard is 60%) respectively. Actions: • As referral outcomes require manual input of data in the majority of cases,

Clinical Lead to ensure all consultants are inputting data promptly. • Monitoring of National Vascular Database data returns. Nurse Practitioner to

contact vascular units every 30 days for surgical update.

An audit to assess the quality of completion of FP10 prescription forms at Intermediate Care and Rehabilitation (ICAR) Unit

This audit identified that the overall quality was good, however there was room for improvement in relation to quantity of medication required and doses prescribed. Actions: • Provide further education for staff to ensure that they clearly document quantity

of drug required on the FP10 prescription form. • Provide further education for staff to ensure that the dose of the drug is clearly

documented and to use the British National Formulary for clarification if required.

An audit to determine whether the time taken from Breast Magnetic Resonance Imaging (MRI) request to second look Ultrasound (US) is fast enough

Out of the 29 preoperative MRI cases identified, results were as follows; standards set: MRI performed within 14 days of request, MRI reported within 7 days. Second look US within 7 days of MRI report. Average wait for MRI 10 days. Average interval to second look at US 6.8 days. Actions: • Discuss the possibility within radiology department and MRI of reserve slots for

patients requiring a breast MRI ‐ Following discussions on logistics with MRI staff and radiologists, it was agreed that reserved slots not likely to be beneficial. Agreed action point 2 and 3 as alternative.

• Improve the vetting of MRI requests by breast radiologist prioritising the vetting of the referrals.

• In order to improve reporting times, the admin staff will now send email when breast MRI appointment made and / or when scans performed.

• In order to streamline the second look US pathway, the radiologist will be responsible for arranging the second look.

• More radiologists to report breast MRI, this will be added into the Personal Developments Plans of radiologists. Two radiologists within the department will take the lead to gain experience of breast MRI with a view to sharing reporting duties.

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Local Clinical Audit Priority for ImprovementAn audit to measure whether the first physiotherapy input following an operation for a fractured hip is compliant with NICE guidance

The audit demonstrated very high levels of compliance at 92.5%. However the following actions have been implemented to improve compliance further in relation to ensuring that rehabilitation staff are aware of the NICE guidelines. Actions: • Results have been shared with rehabilitation staff and education and training

strategies have been implemented to raise the awareness of the NICE guidelines for hip fracture rehabilitation and documentation required.

An audit to assess whether the QE Physiotherapy department practice is compliant with NICE guidance in relation to the management of Lower Back Pain (LBP) in the community setting

The audit demonstrated that we meet some of the NICE guidelines for the treatment of ‘non‐specific’ low back pain. However we are not able to demonstrate from our clinical documentation that all criteria are being met. There is room for improvement in relation to documentation of essential information in the patient notes, increase the number of patients are given written information also referral and uptake of acupuncture treatment. Actions: • To update and make changes to dendrite system (computerised patient

information system) to improve efficiency and also make certain data collection mandatory i.e. the timescale and type of back pain assessed.

• Feedback to staff the results and recommendations to improve practice in line with NICE guidelines.

An audit to establish the level of compliance with NICE guidelines for the treatment of elderly patients with Bipolar Disorder

Of the 14 elderly patients’ notes reviewed, four patients were treated in line with guidelines and were on monotherapy on one of the agents described by the guidelines. Of the 10 patients on combination therapy, 75% followed the guidelines on how to move to combination therapy. The physical review was not documented in all cases and the blood pressure was mentioned only to 78% of patients. More detailed documentation of physical review is needed. Guidelines encourage trying a second monotherapy before switching to a combination of therapies. Actions: • Consultants to be informed of the results and advised to try a second

monotherapy when the first is not successful for elderly patients with Bipolar Disorder.

• The need for more detailed documentation of physical review to be fed back to the Consultants.

An audit to establish the level of compliance with NICE guidelines for Transient Ischaemic Attack (TIA) particularly ‐ at admissions to the TIA Clinic, subsequent diagnosis, treatment and management

Of the 31 patients audited 24 were high risk, seven were low risk. 27 had documentation regarding initial assessment. Of the high risk patients eight were not seen within 24hrs in clinic – this may possibly be due to patients choosing to wait over the weekend to attend a clinic appointment at Gateshead rather than attend a weekend clinic appointment at one of our partner hospitals. All patients had appropriate investigations performed. There is room for improvement in relation to documentation of antiplatelet prescription. Actions: • Amend the ABCD assessment form to include additional tick boxes for

antiplatelets.

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Local Clinical Audit Priority for ImprovementAn audit to determine whether patients with Inflammatory Bowel Disease (IBD) who are started on biological drugs are appropriately selected, screened and managed

The audit demonstrated there is room for improvement. As a result of these results, screening has now been incorporated into the nurse specialist role. This includes screening patients prior to anti‐Tumour Necrosis Factor alpha medications, and patients are now routinely screened for hepatitis B and C, VZW and Tuberculosis (TB) as well as Epstein‐Barr Virus (EBV), HIV and faecal infection. Actions: • Re‐audit in 12 months to determine whether changing the role of the nurse

specialist has had a positive impact on the screening of patients.

Is the timing of the first dose of antibiotics in Neutropenic Sepsis given in line with Trust guidelines?

The results show that of the 13 patients included in the audit, one received the required antibiotics within the target of one hour. The delays for the other 12 were mostly in relation to the time taken for the patient to be reviewed by a doctor, however in one case the delay was in relation to antibiotics being prescribed and administered by a member of the nursing staff. The following actions have been identified in order to improve the time in which antibiotics are administered. Actions: • Warning cards to be made available for at risk patients to avoid delays. • Box for stat doses to be placed on the ward to act as a reminder. • Warning flag system to be implemented within the Medical Admissions Unit –

this action has been implemented – a new board has been developed which includes an early warning score and a red flag system for patients.

Assessment of the management of children presenting to the Accident and Emergency Department in severe pain following the introduction of intranasal diamorphine.

The audit demonstrated that intranasal diamorphine is being used appropriately and safely and in the majority of cases, supplementary analgesia was also given. However, there is scope to improve documentation of pain score reassessment and the dosing of intranasal diamorphine and the timeliness of analgesia. Actions: • Undertake training and education with staff to reiterate the importance of

prompt pain assessment and the use of pain assessment tools and the need for reassessment in 60 minutes.

• Development and implementation of ‘Pain Passports’ to be distributed to parents & children to empower them to reassess pain.

• Undertake training and education for nurses and doctors to recognise prompt need for intranasal diamorphine and correct prescription.

An assessment of whether head injuries, are being documented appropriately to enhance both patient safety and good medical practice.

The audit demonstrated that overall documentation was good but there was improvement to be made in legibility of data, documentation of consciousness and other key features from NICE guidance related to head injury and use of head injury advice cards. Actions: • Summarise the results of the audit onto a poster to display in the Accident &

Emergency doctors office. • Undertake training and education with the junior doctors within Accident &

Emergency in relation to the areas that require improvement.

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Local Clinical Audit Priority for ImprovementAn audit to assess whether Abbreviated Mental Test Scores (AMTS) are being undertaken on admission

The results have demonstrated that improvement is required to meet the target of 90%. People admitted with confusion should have at least an attempted AMTS – the results demonstrated that for the patients included in the audit only 56% had had an AMTS undertaken. Actions: • Provide education and training to team responsible for doing AMTS e.g. MAU

staff/Care of the Elderly. • Change location of AMTS box to bottom of history sheet as it is currently hidden

in the middle of neuro exam section on the clerking proforma. • Include reminder in red/bold above AMTS box e.g. must be completed for ALL

patients over 65. • Include prompt for documentation of the reason why the AMTS was not

completed (e.g. low Glasgow Coma Scale/patient refused).

An audit to measure compliance with the Trust’s Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy

The audit demonstrated good compliance with the policy and that the DNACPR forms are being completed accurately. However it did highlight an area for improvement in relation to patients readmitted with a DNACPR being reviewed on re‐admission. Actions: • Investigate possibility of including DNACPR status on patient electronic

whiteboards to ensure that patient’s resuscitation status is identified at all times. • Amend the DNACPR form to include the location of where the form was initiated.• Further education and awareness raising through mandatory training and

induction for with medical staff of 1) the need to sign the appropriate location on the DNACPR form for decision making, 2) the need for senior medical staff to countersign (within five days of decision) when junior staff have implemented the DNACPR, 3) the need to review existing DNACPR decision on all patients admitted to the hospital.

• Continue to work with SafeCare and Acute Response Team (ART) to identify ways to prevent patient deterioration and recognise when a DNACPR order should be considered.

• Monitor the implementation of new DNACPR orders compared with cardiac arrest calls

An audit to assess whether prevention and treatment of pressure ulceration is appropriate on the Trauma and Orthopaedic Ward

The results provided evidence of high quality care provided to patients with a fractured neck of femur in many cases. Improvement required in some areas so that fractured neck of femur patients are well supported post operatively. Actions: • A programme of training and education to be developed with regards to 1)

documentation of the use of Care Standard 15 2) raise awareness with staff of the need to document when patients receive snacks other than supplementary drinks recorded on the drug chart, 3) raise awareness with staff of the need to document skin inspection at the end of each shift and record keeping by nursing staff including incident reporting and 4) raise awareness with staff of the need to record positional changes chart, food/fluid balance charts in order to support best practice.

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Local Clinical Audit Priority for ImprovementA re‐audit of the use of tension free vaginal tape intervention for stress incontinence

The results demonstrated that 100% of patients were offered conservative management and the surgeons undertaking the procedure were appropriately trained. No bladder perforations recorded in the sample. However improvements could be made in relation to assessing the patient’s quality of life before and after the procedure. Actions: • Inform surgeons undertaking the procedure that quality of life questionnaires

should be completed with the patients both before and after the procedure. • Enter data onto the British Society of Uro‐Gynaecology database to compare

performance with other surgeons across the country. • Re‐evaluate level of training provided to the specialist registrar. The small

sample size of the audit must be taken into consideration as they may not accurately represent the professional’s performance.

• NICE guidelines recommend the patients should receive three months of conservative management prior to any surgical treatment. In order to ensure that we are meeting this, the time the patients undertake the Pelvic Floor Exercises Trial must be documented.

An audit to assess whether the appropriate method of Surgical Management of Ectopic Pregnancy is being used

The results of the audit demonstrated that women with ectopic pregnancies attending this hospital are overall experiencing good care with regards to surgical approach and seniority of care. However it did identify that improvements can be made regarding communication with discharge letters and handover of care to General Practitioner (GP). This audit covered a time when the new system for electronic discharge letters was implemented and this may have had an impact on this. The local guidelines recommend that three weeks following theatre patients should do a pregnancy test, it was not clearly documented if this was advised. There is also room for improvement in the documentation of post‐operative advice being given. Actions: • Raise awareness, at the Divisional SafeCare Meeting, the need to improve the

post‐operative advice given to patients and documentation of this and also the need to improve discharge communication with the GP.

An audit to ascertain whether non‐pregnant patients admitted with abdominal pain are being managed appropriately

Good practice was identified in relation to documenting pain scores, with 100% of patients having their pain score documented. However it identified that improvement was required in relation to the documentation of swabs being taken on patients with pelvic inflammatory disease in order to administer the correct prescription of antibiotics, appropriate completion of discharges on electronic system and ultrasound scan being done within 48 hours. Actions: • Amend clinical guideline for management of pelvic inflammatory disease and

update Obstetric and Gynaecological doctors local induction booklet, to reflect good practice.

An assessment of whether the Standard Orthopaedic Admissions Proforma (SOAP) is being used appropriately

Good practice was identified in relation to history of presenting complaint and past medical history and completion of Deep Vein Thrombosis (DVT) risk section. However the audit did identify areas for improvement in relation to the documentation of physical examination being undertaken. Actions: • Further education of Senior House Officers to stress the importance of

completing each element of the SOAP.

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Local Clinical Audit Priority for ImprovementAn audit to measure patient experience and satisfaction with the Ileo Anal Pouch Service

The patient satisfaction survey demonstrates patient’s overall experience as good particularly in relation to after care in the Stoma Clinic and receiving good support and advice both pre and post operation. One area highlighted for improvement was more involvement at ward level, ward staff to take an active role in stoma care when stoma nurse not available. The following actions have been/will be taken to improve the service. Actions: • Provide information to patients regarding where they can access support and

advice. • Raise awareness with the ward staff regarding patient education particularly at

the weekend when stoma nurses are not on site. • Provide patients with the necessary contact numbers should they need to

contact staff for further advice and support.

An audit investigating the timing of haemoglobin drop after fractured neck of femur (hip)

The results of the audit were very good, 100% of patients had a haemoglobin check on admission. 97% of patients had a haemoglobin check on Day 1 following their operation. The following action has been identified to improve the service even further. Actions: • Discussions to take place with the Anaesthetics Department to develop a

strategy to ensure that 100% of patients have a Haemacue blood test during the operation.

An audit to determine whether we are following NICE Guidelines for post‐operative varicose vein surgery

The results demonstrated excellent levels of compliance in relation to each patient having an operation note (100%). However, it did identify that improvements are required to be made in relation to the use of compression hosiery. Varying instructions were given to patients; 28% had no instruction given, 51% were told to wear compression hosiery for six weeks, 7% for four weeks and 14% for five days and nights then 10 days only. NICE guidelines recommend that stockings should be worn for no longer than seven days. Actions: • Amend post‐operative instruction leaflet to state that compression stockings are

used for seven days only and patients are given one pair of stockings only. • Raise awareness of the amended post‐operative instruction leaflet with the staff

in the theatre Pods. • Re‐audit in 12 months to ascertain whether this has had a positive impact on the

service.

Have actions identified as a result of the initial audit into whether we are following NICE Guidelines for post‐operative varicose vein surgery had a positive impact?

The results of the re‐audit demonstrated that 58% of the 24 patients received post‐operative instructions that prescribed the use of stockings for seven days (as per NICE guidance). This has highlighted that the actions identified from the initial audit undertaken from July‐October 2013 have had a positive impact as previously 51% of patients were prescribed stockings for six weeks following Varicose Vein surgery. Although the audit has demonstrated an improvement in compliance with NICE guidance, there is still room for improvement and the following actions have been identified. Actions: • Further raise awareness with nursing team in day case unit that stockings should

be prescribed for no longer than seven days, unless clinically indicated on post‐operative notes.

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Local Clinical Audit Priority for ImprovementAn audit to look at the reasons for Surgical Site Infections (SSI) from April 2012 to April 2013

Overall the results show a good standard of practice, particularly in relation to the recording of the SSIs being correct in the majority of cases. However the results did identify that there is improvement required which resulted in the following actions: Actions: • In‐house training and awareness sessions for clinicians on diagnostic criteria for

SSIs. • Awareness campaign to include literature/posters on wards and doctor’s offices

to highlight importance of clarifying nature of any post‐operative collection in the GP handover summaries.

• Present results of the audit to Consultant Surgeons to raise awareness of the importance of coding SSIs correctly.

• Work with the Coding Department to ensure that they understand the importance of the correct coding of SSIs with a view to possibly changing the current practice.

• Undertake a re‐audit to look at the SSI coding accuracy.

An audit to measure whether patients are prescribed the appropriate duration of antibiotic treatment

The results identified that documentation of diagnosis and choice of antimicrobial in medical notes was excellent, most patients received the correct antibiotics for their diagnosis, antimicrobials were reviewed prior to or on the day of suggested review in the majority of cases. No doses of antibiotics were missed and no patients were prescribed an antibiotic that they were allergic to. Documentation could be improved in relation to antimicrobial choice, duration of treatment and diagnosis in the medications charts. Some patients did not receive the recommended length of course of antibiotics which may have been as a result of poor documentation. Actions: • Further education for prescribing medical clinicians on antimicrobial prescribing. • Re‐audit of antimicrobial prescribing to continuously monitor improvement.

A re‐audit of Endoscopic Retrograde Cholangio‐Pancreatography (ERCP) practice at the Queen Elizabeth Hospital

The audit demonstrated that the service is being run in accordance with the British Society of Gastroenterology Quality and Safety Indicators for Endoscopy – Joint Advisory Group on Gastro Intestinal Endoscopy. The Trust complication rate appeared to be in the normal range. The Trust’s quality standards are above the minimum. However the audit did identify that there was variation in the quality of data entry. Actions: • Undertake a separate audit to look at complication rate of ERCP practice. • Develop the audit further with a view to collecting data prospectively.

An audit to determine whether Bowel Cancer Screening Programme documentation sent from the hub is being filed within the patient’s health records at their local hospital

The audit showed that documentation is not consistently being filed appropriately in the patient’s health records at their local hospital. The following actions have been identified:‐ Actions: • Further awareness raising with Consultant secretaries regarding the need to file

documentation appropriately. • Proforma to be developed to record documentation that has been sent for filing. • Inform consultant secretaries when the documentation has been sent so they

are aware to look out for it.

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Local Clinical Audit Priority for ImprovementAn audit to determine whether we are prescribing food thickeners appropriately

The overall performance was good, however there are areas for improvement, particularly; reporting Speech and Language Team (SALT) Assessment to GPs and poor prescription rate of food thickener. By implementing the following actions the quality of care will be improved: Actions: • Add a specific section for SALT on discharge prescription the same as the

“Transfusion” section

An audit to establish referrer compliance with the radiology auto report protocol

When issued, reports by the clinician are consistently accurate with no evidence from this audit of significant, management‐altering discrepancies or significant ‘misses’. However the audit did highlight low rate of reports documented in the case notes. Actions: • Ionising Radiation Medical Exposure Regulations (IRMER) representative to

attend a session with Orthopaedic Surgeons to raise awareness of their responsibilities under the IRMER.

• Raise awareness of the importance of recording plain film findings in the patient record to all grades of medical staff.

• Re audit of all patients on the Orthopaedic ward to determine whether findings are consistently being recorded in the patient notes.

• Orthopaedic Consultant lead and the junior medical staff to develop a robust method of recording findings e.g. revising care pathway or discharge letter template.

• Re‐audit to ascertain whether the actions identified have made any improvement.

An audit to establish whether Clinical Supervision is being used within the Trust

The results of the audit confirmed that following the implementation of a clinical supervision steering group and formal training that clinical supervision is now taking place in clinical areas. However in order to ensure that this practice continues, the following actions have been identified. Actions: • Share results with Nursing and Midwifery Forum and Clinical Leads Day • Ensure all clinical areas have the 2014 clinical supervision training days planned

into their rosters • Re‐audit annually

An audit to establish whether the number of ultrasound machines for use within the Anaesthetics Department is sufficient

The use of ultrasound within the Anaesthetic Department is on the rise, the results of the audit demonstrated two ultrasound machines is not sufficient to meet the needs of the service. 9% of procedures were delayed as a result of tracking down an ultrasound machine and 5% of procedures were delayed due to the time waiting for an ultrasound machine. The following actions have been identified to address this issue. Actions: Develop and present a business case for the purchase of an additional Ultrasound Machine.

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Local Clinical Audit Priority for ImprovementAn audit to establish whether we are meeting the needs of younger patients with Dementia

Overall the service meets recommendations in the provision of age appropriate services, carers support and community groups. However improvements can be made in relation to working more collaboratively with the Neurology Service and providing support to patient in relation to local drug and alcohol services. The following actions have been identified. Actions: • Look into the possibility of making the physical environment more accessible to

patients with mild dementia • Update referral forms to ensure all appropriate information can be captured • Update information leaflets regarding service • Develop closer links with substance misuse services and Neurology services • Update other health professionals about the nature of the service through

meetings or information leaflets.

An audit to determine whether patients detained within Queen Elizabeth Hospital are given information regarding their right to support from the Mental Health Advocacy Service.

A total of 21 set of detention papers were eligible to be included in the audit. Out of those, three patients refused the advocacy service and had the capacity to do so, therefore were not included in the results. Therefore 18 patients have been included in the audit results. 33% of patients requested a referral to the Service and had the capacity to make that decision. 44% of patients did not have capacity to make a decision regarding the Advocacy service and a referral was made in their best interests, 11% of patients refused the use of the Advocacy Service but the capacity assessment indicated they did not have capacity to make this decision and 11% of patients paperwork was not completed and information from the Mental Health Advocacy Service indicates that no referral was made for these patients. 22% of detained patients should have been referred to the Advocacy Service in their best interests. The following actions have been identified. Actions: • Further raise awareness with staff that they should refer any patient who does

not have the capacity to understand their rights under the Mental Health Act Section 132 to the Advocacy Service as this is in their best interests.

• Amend local detention paperwork to indicate whether referral has been made in best interests of the patient.

• Amend local paperwork in order to provide to evidence that patient’s who have previously refused the advocacy services are reminded at regular intervals of their right to support from the service.

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Participation in clinical research The number of patients receiving relevant health services provided or sub‐contracted by Gateshead Health NHS Foundation Trust in 2013/14 that were recruited during that period to participate in research approved by a research ethics committee was 1,633. Although a slight drop in recruitment from last year, it has been another successful period for Research & Development within the Trust. Participation in clinical research demonstrates Gateshead Health NHS Foundation Trust’s commitment to improving the quality of care we offer and making our contribution to wider health improvement. Our clinical staff stay abreast of the latest possible treatment possibilities and active participation in research leads to successful patient outcomes. In line with Northumbria, Tyne & Wear ‐ Comprehensive Local Research Network (NTW CLRN), the Trust has focused on building the recruitment for both Portfolio and Industry studies. Gateshead Health NHS Foundation Trust was involved in conducting 246 clinical research studies in a variety of areas including – cancer, dementia & neurodegenerative disease, diabetes, medicines for children, mental health, stroke, rheumatology, gynaecological oncology, obstetrics and various specialty groups between 2013/14. Over the last year, researchers from the Trust have published over 110 publications and delivered 21 presentations to a variety of audiences, the majority of which are as a result of our involvement in NIHR research, which shows our commitment to transparency and desire to improve patient outcomes and experience across the NHS. There were 115 clinical staff participating in research approved by a research ethics committee at Gateshead Health NHS Foundation Trust during 2013/14. These staff participated in research covering nine medical specialties. Our engagement with clinical research also demonstrates Gateshead Health NHS Foundation Trust’s commitment to testing and offering the latest medical treatments and techniques. The Trust was placed 63rd out of 388 Trusts within the Guardian Research League Table for the number of recruiting portfolio studies (75) in 2013. The Trust also underwent an MHRA Statutory GCP Inspection led by Dr Vincent Yeung, GCP Operations Manager & Senior GCP Inspector. The Inspection looked at all aspects of Good Clinical Practice (GCP) for the Trust Sponsored studies and was very successful with no critical findings reported and only four major findings listed. The Research & Development Team continues to grow with the appointment of a Cardiology Research Nurse and Research Midwife – supporting and growing areas of great research potential within the Trust. The Research & Development Team hosted an Information Event within the hospital dining room on International Clinical Trials Day – 20th May 2013, to highlight the different areas of research within the Trust for both patients and staff. The Event was well received alongside the research promotional items. Use of the Commissioning for Quality and Innovation Framework A proportion of Gateshead Health NHS Foundation Trust income in 2013/14 was conditional upon achieving quality improvement and innovation goals agreed between Gateshead Health NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2013/14 and for the following 12 month period are available electronically at http://www.qegateshead.nhs.uk/cquin

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A monetary total of £3,939,000 of the Trust’s income in 2013/14 was conditional upon achieving Quality Improvement and Innovation Goals. The Trust were paid a total of £3,787,000 for achieving the Quality Improvement and Innovation Goals for 2012/13. Registration with the Care Quality Commission (CQC) Gateshead Health NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. The Care Quality Commission has not taken enforcement action against Gateshead Health NHS Foundation Trust during 2013/14. Gateshead Health NHS Foundation Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reporting period. The Care Quality Commission made two unannounced visits during 2013/14 to carry out routine Mental Health Act monitoring visits of detention in hospitals. The first visit was carried out in July 2013 and covered Ward 23. The second visit covered detention in hospital for acute admissions and involved Cragside Court. There were no compliance issues identified in either of the inspection visits. The Care Quality Commission undertook an unannounced planned review of compliance in December 2013 to observe and check how people were being cared for at each stage of their treatment and care. Areas inspected included the accident and emergency department, the medical assessment unit and the associated wards 3, 23, 24 and 25.The report concluded that the patient and staff feedback during the inspection was universally positive and all standards inspected had been met. Data Quality Gateshead Health NHS Foundation Trust recognises that it is essential for an organisation to have good quality information to facilitate effective delivery of patient care and is essential if improvements in quality of care are to be made. Gateshead Health NHS Foundation Trust submitted records during 2013/14 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data is shown in the table below: Which included the patient’s valid NHS Number was: Trust %* National %* Percentage for admitted patient care 99.5% 99.1% Percentage for outpatient care 99.2% 99.3% Percentage for accident and emergency care 95.6% 95.7%

Which included the patient’s valid General Medical Practice: Trust %* National %* Percentage for admitted patient care 100.0% 99.9% Percentage for outpatient care 100.0% 99.3% Percentage for accident and emergency care 100.0% 99.1%

*SUS Data Quality Dashboard – Based on provisional data April 2013 to January 2014 SUS data at the month 10 inclusion date Information Governance Toolkit Gateshead Health NHS Foundation Trust’s Information Governance Assessment Report overall score for 2013/14 was 87% and was graded Green (satisfactory).

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Standards of Clinical Coding Gateshead Health NHS Foundation Trust was subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission and the error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were:

Coding Achievement Trust % Primary diagnoses incorrect 10% Secondary diagnoses incorrect 11.2% Primary procedure incorrect 8.8% Secondary procedure incorrect 11.1%

The results of this audit should not be extrapolated further than the actual sample audited. The audit sample for 2013/14 was 100 FCE’s from a national theme of Paediatrics and 100 FCE’s from the specialty of General Medicine which was a locally defined selection. An external Quality Assurance Programme has also been carried out within Clinical Coding, this programme consisted of a number of audits and also required all clinical coders within the Trust to complete an assessment paper. The audits focused on areas of activity related to mortality coding and the results of the audits showed a primary diagnosis error rate of 8.9% and a primary procedure error rate of 6.7%. In addition audits were carried out at individual coder level, the results of the coder level audits were; primary diagnosis incorrect 3.7%, secondary diagnosis incorrect 4.0%, primary procedure incorrect 3.1%, secondary procedure incorrect 3.4%. All of the clinical coders within the Trust also sat a three hour assessment paper that was designed to test the coder’s skills in performing their role effectively. The entire team achieved or exceeded the target pass mark of 80%, it was noted in the report provided by the external assessors that ‘given the content of the paper, the results achieved were outstanding’. The results of all of the audits and the assessment provided the Trust with external assurance that the quality of the clinical coding within the Trust was of a very high standard. In addition the assessment paper demonstrated that the coders within the Trust have received the appropriate training to apply the rules and conventions of clinical coding accurately. Gateshead Health NHS Foundation Trust will be taking the following actions to improve data quality: • Data Quality Strategy Group which includes key staff from all specialties to highlight and drive

continual improvement. • Continual development of our Data Quality Metrics to ensure all appropriate indicators are covered

and align to national and local quality indicators. • Continue with daily batch tracing to ensure the patient demographic data held on our PAS matches

the data held nationally. • Circulate weekly patient level reports to allow the clinical services to fully validate 18 week and

cancer pathways. • Spot check audits to randomly select patients and correlate their health record information with

that held on electronic systems. • Continue to work the data quality leads throughout the Trust to promote and implement data

quality policies and procedures to ensure that data quality becomes an integral part of the Trust’s operational processes.

• Clinical Coding Quality Assurance Programme to provide assurance on the quality of coding within the Trust.

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2.4 Mandated Core Quality Indicators Since 2012/13 NHS Foundation Trusts have been required to report performance against a core set of indicators using data made available to the Trust by the Health and Social Care Information Centre (HSCIC). SHMI (Summary Hospital‐level Mortality Indicator) Gateshead Health NHS Foundation Trust considers that this data is as described for the following reasons:

• The Summary Hospital‐level Mortality Indicator (SHMI) reports mortality at a trust level across the NHS in England and is regarded as the national standard for monitoring of mortality. For all of the SHMI calculations since October 2011, death rates (mortality) for QE Gateshead are described as being ‘as expected’.

Gateshead Health NHS Foundation Trust has taken the following actions to improve the indicator and percentage in (a) and (b), and so the quality of its services, by [please see pages 8 ‐15]. Gateshead Health NHS Foundation Trust intends to take the following actions to improve the indicator and percentage in (a) and (b), and so the quality of its services, by [please see pages 37‐39].

The value and banding of the

summary hospital level mortality

indicator “SHMI” for the trust for the reporting period

Metric Jan 11‐ Dec 11

April 11 – Mar 12

Jul 11‐ Jun 12

Oct 11 – Sept 12

Jan 12 – Dec 12

Apr 12 – Mar 13

Jul 12 –

Jun 13

Oct 12 – Sept 13

Gateshead Health NHS Foundation

Trust Value 1.04 1.03 1.05 1.04 1.04 1.03 1.02 1.01

England Value 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

England highest Value 1.24 1.24 1.3 1.21 1.19 1.17 1.16 1.19

England lowest Value 0.69 0.71 0.71 0.68 1.11 0.65 0.63 0.63


Trust Banding 2 2 2 2 2 2 2 2

England Banding 2.04 2.04 2.04 2.06 2.02 2.07 2.06 2.06

England highest Banding 1 1 1 1 1 1 1 1

England lowest Banding 3 3 3 3 2 3 3 3

Banding 1 – where the trust’s mortality rate is ‘higher than expected’ Banding 2 – where the trust’s mortality rate is ‘as expected’ Banding 3 – where the trust’s mortality rate is ‘lower than expected’

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The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting

period

Jan 11‐Dec 11

Apr 11‐Mar 12

Jul 11‐ Jun 12

Oct 11‐Sep 12

Jan 12 – Dec 12

Apr 12 – Mar 13

Jul 12 –Jun 13

Oct 12 –Sep 13

Gateshead Health NHS Foundation Trust 10.4% 9.9% 11.9% 13.63% 14.6% 14.7% 13.7% 12.9%

England highest 41.7% 44.2% 46.3% 43.3% 42.7% 44% 44.1% 44.9%

England lowest 0.4% 0.2% 0.3% 0.2% 0.1% 0.1% 4.2% 2.7%

England 17.2% 17.9% 18.4% 19.20% 19.5% 20.4% 20.65% 21.29%

Patients on Care Programme Approach (CPA) who were followed up within 7 days after discharge from psychiatric in‐patient care Gateshead Health NHS Foundation Trust considers that this percentage is as described for the following reasons: • The Trusts closely follows and adheres to the standards set out within the DOH guidance.

Compliance is monitored closely by the Trust and CQC and any issues with compliance are escalated to Mental Health Committee a subcommittee of the board.

Gateshead Health NHS Foundation Trust intends to take the following actions to maintain this percentage, and so the quality of its services, by continuing to closely monitor compliance.

Proportion of patients on CPA who were followed up

within 7 days after discharge from psychiatric

inpatient care

Apr – Jun 12

Jul – Sep 12

Oct – Dec 12

Jan – Mar 13

Apr – Jun 13

Jul – Sep 13

Oct ‐ Dec 13

Jan – Mar 13


Nil return*

100.% 100.% 100% 100.% 100% Nil return* 100%

England highest 100% 100%

England lowest 77% 93.3%

England 97.5% 97.2% 97.6% 97.3% 97.4% 97.5% 96.7% 97.4% * There were no qualifying patients for this period PROMs (Patient Reported Outcome Measures) for • Groin hernia surgery • Varicose vein surgery • Hip replacement surgery • Knee replacement surgery

Gateshead Health NHS Foundation Trust considers that the outcome scores are as described for the following reasons:

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Groin • Our outcomes are in line with the national normal distribution using the EQ‐5D measure. • We will continue to share data with clinical teams and commissioners to ensure that health gains

can be maximised from future procedures. We will also discuss with patients considering surgery the range of outcomes that can be expected to ensure they have an informed choice of treatment, including alternatives to surgery where appropriate.

Veins • Our outcomes are in line with the national normal distribution using the EQ‐5D measure, however

using the Aberdeen Varicose Vein Questionnaire we are a positive outlier. • We will continue to share data with clinical teams and commissioners to ensure that health gains

can be maximised from future procedures. We will also discuss with patients considering surgery the range of outcomes that can be expected to ensure they have an informed choice of treatment, including alternatives to surgery where appropriate.

Hip • Our outcomes are slightly below distribution using the EQ‐5D but still within the recommended

parameters. • We will continue to share data with clinical teams and commissioners to ensure that health gains

can be maximised from future procedures. • See below for other actions taken to improve our outcome scores. Knee • Our outcomes are in line with national normal distribution using the EQ‐5D. • We will continue to share data with clinical teams and commissioners to ensure that health gains

can be maximised from future procedures. • See below for other actions taken to improve our outcome scores. Gateshead Health NHS Foundation Trust has taken the following actions to improve these outcome scores, and so the quality of its services, by: • Emphasising the importance of completing the six month questionnaire at pre‐assessment and

joint care clinic. • Introduced script for pre‐assessment staff to ensure standardisation. • Revised the Patient Information Booklet for total hip replacement. • Revising the Patient Information Leaflet for total knee replacement. • Reinstated hip class for post‐operative patients with open access. • Established MDT group to review joint care pathway. • Introducing a ‘What to do at 6 weeks’ booklet for post‐operative patients. • Introduced a Shared Decision Making Option Tool into out‐patient clinics for patients with hip and

knee pain.

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EQ‐5D index case mix adjusted health gain

Adjusted average health gain

Period Location Groin Hernia

Varicose Vein

Hip Replacement

Knee Replacement

Apr 13‐Sept 13*

Gateshead Health NHS Foundation Trust 0.065 0.105 0.37 0.30

England 0.086 0.102 0.447 0.339

Apr 13‐Sept 13* England high 0.2 0.23 0.724 0.683

Apr 13‐Sept 13* England low ‐0.033 ‐0.043 0.177 0.073

Apr 12‐Mar 13*


England 0.085 0.093 0.438 0.319

Apr 11 ‐ Mar 12


England 0.087 0.094 0.416 0.302

Apr 10 ‐ Mar 11


England 0.085 0.131 0.405 0.299

Apr 09 ‐ Mar 10


England 0.085 0.091 0.405 0.299

*Provisional figures which will be finalised August 2014 Emergency Readmissions within 28 Days • Aged 0 – 15yrs • Aged 16yrs or over The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the following reasons: • Health profile of Gateshead residents‐ we report higher incidences of deaths relating to cancer,

Cardio Vascular Disease (CVD) and Chronic Obstructive Pulmonary Disease (COPD). Overall long term conditions account for 10.92% of all admissions based on the criteria of the long term condition being identified in the primary diagnosis

• Gateshead and the surrounding areas is one of the poorest and most deprived in the country. • The largest number of readmissions are attributed to patients aged 75‐85 years old • Acknowledged system wide issues across health and social care organisations • In relation to children’s service we no longer provide in‐patient services. The new model of care

that the Trust provides is that of an initial assessment for a period of up to 24 hours. Any child requiring care for a longer duration is transferred to an appropriate children’s centre.

The Gateshead Health NHS Foundation Trust has taken the following actions to improve these percentages, and so the quality of its services, by [please see pages 18 to 20]

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The Gateshead Health NHS Foundation Trust intends to take the following actions to improve these percentages, and so the quality of its services, by [please see page 20]

Indirectly age, sex, method of admission, diagnosis, procedure standardised per cent

Emergency readmissions within 28 days Aged 0‐15 years 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Gateshead Health 10.12 8.35 8.55 8.85 9.30 9.44

England 9.54 9.94 10.09 10.18 10.15 10.01

Highest medium acute trust 14.99 18.61 17.34 14.20 14.76 13.58

Lowest medium acute trust 6.63 4.77 5.10 6.33 6.04 5.10

Indirectly age, sex, method of admission, diagnosis,

procedure standardised per cent

Emergency readmissions within 28 days Aged 16 years or over 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Gateshead Health 11.83 11.51 11.78 12.08 12.34 13.15

England 10.43 10.57 10.90 11.16 11.42 11.45

Highest medium acute trust 12.99 13.32 13.08 13.30 13.00 13.50

Lowest medium acute trust 7.82 8.07 7.92 7.34 7.68 8.96

2012‐13 data to be published December 2014 Trust’s responsiveness to the personal needs of its patients The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the following reasons: • Whilst there has been a reduction in the composite score since 2009/10 the Trust continues to

score higher than the national average. We will continue to focus our work on these important aspects of the patient experience.

The Gateshead Health NHS Foundation Trust has taken the following actions to improve these percentages, and so the quality of its services, by: • Continually monitoring patient feedback through our local patient experience surveys and Friends

& Family Test feedback and acting upon areas for improvement • Developed a new Patient, Public and Carer Involvement and Experience Strategy that sets out a

framework for how the Trust will improve the patient experience over the next three years. It will be delivered through a framework on the concept of ‘5 steps to excellent care’.

The Gateshead Health NHS Foundation Trust intends to take the following actions to improve these percentages, and so the quality of its services, by: • Implementing our strategy through a new Patient Experience and Involvement Group that includes

key internal and external stakeholders such as HealthWatch, Local Authority and Voluntary Groups and Organisations

• Developing and spreading our existing work on customer care • Continually monitoring and acting upon feedback from patients, carers, the public and our staff

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Responsiveness to the personal needs of patients Average Weighted Score 20

03/04

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Gateshead Health NHS Foundation Trust 71.1 71.0 67.0 65.7 73.2 74.0 71.4 71.3 70.3

England Highest 83.3 82.6 84.0 83.1 83.4 81.9 82.6 85.0 84.4

England Lowest 56.0 55.8 55.1 54.6 56.9 58.3 56.7 56.5 57.4

England 67.4 68.2 67.0 66.0 67.1 66.7 67.3 67.4 68.1

2013‐2014 data will be published in August 2014 Percentage of staff employed by, or under contract to, the Trust who would recommend the Trust as a provider of care to their family or friends The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the following reasons: • Certain staff groups, who are perhaps those without direct patient contact, are unable to answer

this question with any certainty • 23% of respondents did not have a view, which suggests that more needs to be done to raise

awareness of the quality of treatment and care within our own Trust. The Gateshead Health NHS Foundation Trust has taken the following actions to improve these percentages, and so the quality of its services, by: • Continued to promote the Trust’s vision and values, which put the patient at the centre of

everything we do • Continued to communicate excellent practice through a range of media and forums, including staff

newsletter articles, patient stories, staff awards ceremony, annual Nursing Conference, good practice events and by attaining further national acclaim for our services

• Exposed more staff to patient feedback and help them see a clear line of sight between their own role and the patient experience

• Continued to involve staff in shaping future services with patient, carer and public involvement • Through recruitment, induction, training and development programmes and through key

communication mechanisms, ensure that all staff are aware of the strengths of the Trust • Through our Recognition Strategy, celebrate achievement of excellent practice and positive

behaviours to engender a sense of pride and confidence in our services • Continued to encourage positive role modelling of leaders at every level and encouraging

innovation and service improvement through staff

Staff who would recommend the Trust to their family or friends 2010 2011 2012 2013

Gateshead Health NHS Foundation Trust 70% 73% 69% 69.7%

England highest 94%

England Lowest 39.6%

All Acute Trusts 66% 65% 65% 67%

2014 data will be published in 2015

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Percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the following reasons: The Trust has made significant improvements in the screening of patients for risk of VTE where we have moved from a position of 48% compliance for the period July‐ September 2010/11 to maintaining over 95% compliance since July 2013. The Gateshead Health NHS Foundation Trust intends to take the following actions to improve these percentages, and so the quality of its services, by • Reviewing electronic systems for undertaking and recording VTE risk assessment • Further developing our programmes of education and uptake of these • Continually monitor performance and take action where necessary • Reinvigorate our VTE awareness campaign Percentage of admitted patients risk‐assessed for VTE

Apr 12

May 12

Jun 12

Jul 12

Aug 12

Sep 12

Oct 12

Nov 12

Dec 12

Jan 13

Feb 13

Mar 13


93.0% 92.9% 92.4% 92.4% 90.8% 92.3% 90.6% 92.1% 90.8% 91.6% 92.0% 91.9%

All providers of NHS funded acute care

93.4% 93.6% 93.3% 93.9% 93.9% 94.0% 94.3% 94.4% 93.8% 94.3% 94.1% 94.1%

Percentage of admitted

patients risk‐assessed for

VTE

Apr 13

May 13

Jun 13 Jul 13 Aug

13 Sep 13

Oct 13

Nov 13

Dec 13

Jan 14

Feb 14


Trust

91.2% 90.6% 91.34% 95.6% 95.7% 95.6% 95.1% 95.2% 95% 96.1% 96.0%

England Highest 100% 100% 100% 100% 100%

England Lowest 84% 76.1% 71.3% 74.6% 77.0%

All providers of NHS funded acute care

95.1% 95.5% 95.7% 95.1% 95.2% 95.2% 95.9% 96% 95.6% 96.01% 96.0%

Source: http://www.england.nhs.uk/statistics/statistical‐work‐areas/vte/ The rate per 100,000 bed days of cases of C.difficile infection reported within the Trust amongst patients aged 2 or over

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The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the following reasons: The improved performance activity has been successfully achieved through the consolidated efforts of Trust staff and the IP&C team. In order to support a reduction in Clostridium difficile and other infections across the Trust a targeted approach of reducing infection risk and improving compliance for patient safety along with a zero tolerance approach to avoidable HCAI has been implemented. A large number of infection prevention initiatives have been introduced over this period of time to achieve this level of performance. The Gateshead Health NHS Foundation Trust has taken the following actions to improve these percentages, and so the quality of its services by using the following approaches: please see detail on pages 27‐33.

Rate per 100,000 bed‐days for specimens taken from patients aged 2 years and over (Trust apportioned cases)

2008/09

2009/10

2010/11

2011/12

2012/13

Gateshead Health NHS Foundation Trust 52.3 54.8 27.8 16.1 17.5

England highest 128.9 92.0 71.2 58.2 30.8

England lowest 1.2 1.5 2.6 1.2 1.2

England 52.9 35.3 29.7 22.2 17.3

Source:http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/ClostridiumDifficile/EpidemiologicalData/MandatorySurveillance/cdiffMandatoryReportingScheme/ The number and rate of patient safety incidents reported within the Trust and the number and percentage of such patient safety incidents that resulted in sever harm or death. The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the following reasons • Until September 2012 there had been a steady reduction in the per cent of incidents resulting in

severe harm or Death. In October 12 – March 13 there was an increase in this figure. This can be attributed to Inpatient falls resulting in a Hip Fracture being categorised as ‘severe’ harm, where in the past they were categorised as ‘Moderate’.

• The Trust is a very safety conscious organisation and strives to learn lessons learned and outcomes changed as a consequence of the investigations it undertakes using the National Patient Safety Agency RCA documentation. As consequence of this we have seen a reduction in harm from pressure damage.

The Gateshead Health NHS Foundation Trust has taken the following actions to improve these percentages, and so the quality of its services, by • Purchasing the Datix Dashboard module which enables staff throughout the organisation to view

incidents and trending data more efficiently and effectively. • Undertake a weekly safety briefing meeting for all head of services involved in safety and quality

which is attended by the Director of nursing, Midwifery and Quality. During 2014 this will be expanded to include clinical managers through the trust so that they will know in a timely manner (week prior’s data) what the risks and issues are to ensure a more responsive approach to the risks identified.

• Analysing the information received from the Patient Safety Culture to produce Departmental and Trust action plans to improve safety across the Trust.

• Working with our local area team from NHS England in ‘Investing Behaviours’ which uses the Kirkpatrick model to improve training and also ‘insights training’ to improve the communication between staff and patients.

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• Undertaking more investigations using the multidisciplinary approach to RCA’s to ensure lessons are learned by all staff involved in the incidents.

• Combining the SafeCare and risk management strategies into one strategy. The Safecare strategy 2014 ‐ 2017 takes a steam lined approach to reducing harm and improving the quality of patient care.

• Continue to utilise SafeCare Alerts and Good Practice Bulletins to enable the sharing of good practice to inform service delivery and notification of risks and harm that must be remedied.

• Continuing to ensure that all staff are aware of their responsibilities with regard to incidents and Duty of Candour via education and training.

Period Organisation name

Total number of incidents occurring

Rate of all incidents per 100

admissions

Number of incidents resulting in Severe harm or Death

Percentage of total incidents that

resulted in Severe harm or Death

Apr 13 – Sep 13

Gateshead Health NHS Foundation Trust 2180 7.59 19 0.87%

All Medium Acute organisations 133207 631 0.47%

Oct 12 – Mar‐13

Gateshead Health NHS Foundation Trust 2342 8.09 17 *0.73%

All Medium Acute organisations 132052 828 0.63%

Apr‐12 to Sep‐12

Gateshead Health NHS Foundation Trust 2,375 8.2 10 0.42%

All Medium Acute organisations 117,134 875 0.75%

Oct‐11 to Mar‐12



Apr‐11 to Sep‐11



*During this period the trust began to categorise hip fractures sustained as a result of an inpatient fall as serious on the incident reporting system instead of moderate harm as previously reported. These are subsequently uploaded to the NRLS. This decision was made in line with recommendations made in the NPSA report slips, trips and falls in hospital.

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2013/14 has been a successful year in relation to the three domains of quality:

Patient Safety


Patient Experience

3.1 Patient Safety - Trust Infection Prevention and Control work gains 1st place at international congress

Philip Pugh, our Head of Infection Prevention and Control, recently attended the Fourteenth Congress of the International Federation of Infection Control (IFIC) which was held 12th – 15th March in Malta which attracted around 500 international delegates. The theme chosen for the congress was ‘understanding behaviour and implementing change’ for infection prevention and control and had a programme that presented global experiences. Philip submitted an abstract on work the Trust had undertaken dealing with Aspergillus fumigatus, a common fungus that grows in the everyday public environment which was accepted for poster presentation entitled ‘Investigation of Aspergillus fumigatus in a Critical Care Department’. The poster was awarded 1st place and was presented alongside 55 other international poster presentations from countries such as Canada, India, Turkey, Libya, Georgia and a number from Europe. The poster presentation attracted a huge amount of interest and discussion with many delegates.

SafeCare Alerts and Good Practice Bulletins The Trust issues these to relevant staff in response to information we gain through national, regional and local sources such as serious untoward incidents and audits where the potential for local learning and the need for action have been identified. During 2013/14 18 Good Practice Bulletins and nine SafeCare Alerts were issued. Some examples can be seen below.

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Patient Safety Culture Assessment Organisational culture is difficult to define but is vital to address, if our ambition is to be the best in the NHS. Organisational culture can be defined as the assumed understandings between the staff of an organisation. It means that they share views on the way staff should work together and treat each other and their patients. We have an ambition to be an organisation that has a ‘generative’ safety culture, where safety is truly in the hearts and minds of everyone, from senior managers to frontline staff. Developing our culture for safety and quality improvement has been a fundamental element of ‘SafeCare’. We will continue to develop a culture where patient safety and quality care is integral to the business of the organisation. The Trust utilises the Manchester Patient Safety Framework (MaPSaF) to measure its safety culture. The Manchester Patient Safety Framework (MaPSaF) is a tool developed to help NHS organisations assess their progress in developing a safety culture. MaPSaF uses ‘dimensions' of patient safety and for each of these describes what an organisation would look like at five levels of patient safety.

Level Description

1. Pathological Why do we need to waste our time on patient safety issues?

2. Reactive We take patient safety seriously and do something when we have an incident

3. Bureaucratic We have systems in place to manage patient safety.

4. Proactive We are always on the alert/ thinking about patient safety issues that might emerge

5. Generative Managing patient safety is in integral part of everything we do.

Our third and most recent assessment took place in 2013, positively identifying the organisations overall culture as being ‘proactive’. It also helped us to identify areas upon which to focus: • Commitment to continuous quality improvement • Staff education and training • Communication about safety. These have been built into our wider plans for strengthening organisational learning and culture of safety. Harm free care ‐ measured by the NHS Safety Thermometer At QE Gateshead we want to understand the care that we give to our patients as much as possible. To do this we undertake work to help us to examine our care and to help us determine whether patients experience harm whilst in our care. A method we have used to do this is the NHS Safety Thermometer. This is a national initiative which includes improvement tools for measuring, monitoring and analysing patient harm and ‘harm free’ care. The four areas of harm which are measured are: • Pressure damage • Falls • Venous Thromboembolism (VTE) • Catheter related urinary tract infections (UTI’s) We have been collecting data using the Safety Thermometer for almost two years on 100% of our patient once per month. Our clinical staff undertake a monthly data collection which is uploaded to the

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Department of Health. As an organisation we are committed to making a difference at the bedside and reduce harm from occurring to patients whilst in our care. The table below shows the percentage of harm free care we have delivered each month.

The results are shared with clinical staff in a timely manner in order for the results to be analysed at ward level and areas for improvement highlighted and addressed. The information is displayed on each wars Time to Care dashboards which display key information about patient care as well as feedback from our patients. Pressure Ulcers The NHS Safety Thermometer asks the organisation to record old pressure and new pressure damage. An old pressure ulcer is defined as being a pressure ulcer that was present when the patient came under our care, or developed within 72 hours of admission to our organisation. ‘New’ pressure ulcer is defined as being a pressure ulcer that developed 72 hours or more after the patient was admitted to our organisation.

How did we achieve this? Led by the Tissue Viability team and ward nursing teams, the continuous improvement programme for pressure ulcers aims to achieve a reduction in the number of pressure ulcers in the Trust and a reduction in the number of pressure ulcers that deteriorate. The improvement programme continues to focus on clinical practice in terms of: • Pressure ulcer risk assessment undertaken within six hours of admission. • The assessment is to be repeated on transfer, if the patients’ condition changes and on a weekly

basis • Patients at risk of developing pressure ulcers or have existing ulcers have their position changed at

least every two hours • Care Standard 15 ‘Prevention and Treatment of Pressure Ulceration’ is initiated on admission

regarding the expected standard of care to be provided at the bedside • A pictorial guide for appropriate selection of mattresses or cushions which are readily available

across the 24 hour period • Chair Replacement Programme ‐ all the bedside chairs have built in pressure relieving properties • The use of pressure relieving gel heel pads • ‘Save our Skin Campaign’ an SOS sticker is placed on the patient’s white board to identify patients

at risk of pressure ulcers • Repositioning schedule (two hourly positional changes) incorporated into the Trust’s Intentional

Rounding Chart. • A root cause analysis is undertaken for all Trust related pressure damage: Category 2 and above

with the findings presented to the Director of Nursing and shared with ward team so lessons can be learnt.

Month Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar Trust % of Harm Free Care

92.34 92.8 91.48 91.37 93.81 91.71 94.50 92.55 95.33 95.73 92.42 91.18

Month Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar

Sample 457 474 481 452 404 398 434 443 471 492 488 465

PD – All 21 24 21 25 16 21 14 25 26 15 26 26

PD ‐ New 7 7 3 14 5 3 4 3 5 7 7 6

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As part of our strategy for improvement in reducing the number of pressure ulcers we have taking part in a McKinsey Improvement Campaign, focusing our attention on a particular hot spot area in clinical practice. This began in July 2013 on Ward 14, the aim is to eliminate avoidable pressure ulcers and reach a goal of being 90 days free of Trust related pressure damage. This work includes undertaking a daily early detection cluster at the bedside involving the nursing and tissue viability nurse specialist teams adopting a multi‐disciplinary approach. From the early detection cluster a number of PDSA cycles have been initiated and changes in clinical practices tested to measure their effectiveness, the majority of which have been initiated simultaneously and are now embedded into the ward routine. Falls The Safety Thermometer asks the organisation to record the severity of any fall that the patient has experienced within the previous 72 hours in a care setting (including home if the patient is on a district nursing caseload). The number of falls are analysed in order to highlight if the fall occurred whilst the patient was in hospital so targeted work can be undertaken on that ward to reduce the level of harm occurring to patients.


Sample 457 474 481 452 404 398 434 443 471 492 488 465

Falls ‐ New 9 5 8 8 8 4 1 9 8 7 13 11

Led by the falls specialist nurse in collaboration with SafeCare the continuous improvement programme for falls aims to achieve a reduction in overall falls and in particular a reduction in falls resulting in harm. The improvement programme continues to focus on clinical practice in terms of: • Compliance with the slips, trips and falls policy including effective risk assessment. • Use of safety improvement tools including the safety cross, Fallings Stars and the 4 Basics • Use of post falls protocol • Rapid response from falls team • Falls champions • The provision of non‐slip slipper socks • Bed rails assessment Catheter Related Urinary Tract Infections (CAUTI) The Safety Thermometer asks the organisation to record whether the treatment for the urinary tract infection (UTI) started before the patient was admitted to our organisation (old) or after the patient was admitted to the organisation (new). As an organisation we are particularly interested in the number of catheter related UTI’s occurring after admission.


Sample 457 474 481 452 404 398 434 443 471 492 488 465

CAUTI 3 2 9 4 3 7 3 3 4 2 4 2

The Trust continues to aim to reduce all avoidable Health‐Care associated infections; this includes Catheter Associated Urinary Tract Infections (CAUTI). The Infection Prevention and Control Nurses provide on‐going surveillance and follow up of all patients with infections from catheter specimens of urine. If a deviation from the catheter care standard is identified in the care the patient received, then an exception report is sent to the ward manager and modern matron for an action plan to be devised. The catheter care record provides a care bundle for the catheter device management, prompting a daily review of the need for a short term catheter with the aim of reducing the number of catheterisation days,

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therefore directly reducing the patient’s risk of developing a CAUTI. This is audited weekly by each ward to enable the Trust to continually monitor compliance of catheter care management Venous Thromboembolism The NHS Safety Thermometer asks the organisation to record whether or not a patient is being clinically treated for VTE of any type. A patient may be defined as having a new VTE if they are being treated for a deep vein thrombosis (DVT), pulmonary embolism (PE) or any other recognised type of VTE with appropriate therapy such as anticoagulants. If treatment for the VTE was started after the patient was admitted to our organisation, it is counted for this measure as a new VTE. The numbers of new VTE’s remain small each month.


Sample 457 474 481 452 404 398 434 443 471 492 488 465

VTE 6 5 3 2 4 2 3 3 4 2 2 4

The VTE Committee continues to oversee the implementation of guidelines for the prevention and management of thromboembolism within the Trust in line with National Institute for Health and Care Excellence (NICE) and other national guidance. It promotes the education and training of all relevant clinical and support staff and leads multi‐professional clinical audit relating to VTE prevention and care. Audit is now well embedded within the Safety Thermometer framework. Root cause analysis is undertaken on patients with a possible hospital associated thrombosis where they are readmitted to hospital within 90 days of discharge with a diagnosis of deep vein thrombosis (DVT) or pulmonary embolism (PE) or they are discharged from a hospital stay with a diagnosis or DVT or PE. Any learning identified as a result of these RCAs is shared with our clinical teams and our Commissioners. As demonstrated in the table below the Trust has made significant improvements in the screening of patients for risk of VTE where we have moved from a position of 48% compliance for the period July‐ September 2010/11 to maintaining over 95% compliance since July 2013. The table below shows how we compare with other Trusts in the North East and England as a whole. In 2014/15 we aim to continue to improve in this important area of patient safety.

Trust 2011/12 Q4

2012/13 Q1

2012/13Q2

2012/13Q3

2012/13Q4

2013/14 Q1

2013/14 Q2

2013/14Q3

City Hospitals Sunderland 92.1% 91.20% 91.70% 92.3% 94.43% 95.20% 95.53% 95.14%

County Durham & Darlington 93.0% 93.60% 93.40% 93.8% 93.70% 95.13% 95.41% 94.79%

Gateshead Health 92.8% 92.80% 91.90% 91.1% 91.93% 91.04% 95.22% 95.10% North Tees & Hartlepool 93.6% 93.00% 92.20% 93.7% 93.22% 95.42% 95.40% 95.83%

Northumbria Healthcare 91.4% 91.20% 91.70% 88.5% 90.28% 90.78% 92.15% 93.01%

South Tees Hospitals 94.4% 94.00% 91.80% 91.8% 92.48% 95.58% 96.44% 95.86%

South Tyneside 89.6% 91.50% 93.50% 93.6% 92.94% 92.91% 92.71% 95.21% Newcastle upon Tyne Hospitals 98.2% 95.00% 95.00% 95.2% 95.35% 95.81% 96.29% 97.41%

North East 93.39% 92.90% 93.85% 94.1% 94.20% 95.46% 95.51% 95.36% National High 100% 100% 100% 100% 100%National Low 84.60% 87.90% 78.78% 81.70% 77.70%Data source http://www.england.nhs.uk/statistics/statistical‐work‐areas/vte/

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3.2 Clinical Effectiveness Care Quality Accreditation Programme Our ward and department Care Quality Accreditation Programme is used to drive improvements and monitor the quality and effectiveness of patient care. The framework measures the ward and departments progress against the four domains of our Nursing and Midwifery Strategy 2013/16. • Domain 1 ‐ Workforce • Domain 2 ‐ Patient Safety • Domain 3 ‐ Clinical Care • Domain 4 ‐ Patient Experience Each domain contains a set of standard statements and gives examples of the evidence required to evaluate performance. The clinical areas are assessed on each standard through a review of a portfolio of evidence, observations of clinical practice as well as staff, patient and carer and relative interviews. It provides us with ward to board assurance, as well as recognising and rewarding the provision of "excellence as standard".

Outcomes Framework

Everyone Counts

Compliance Framework

Nursing and Midwifery Strategy

Patie

nt Sa

fety

Safeguarding

Harm Free Care for AllInfection Prevention & Control

Patie

nt Ex

perie

nce

Friends and Family Test

Listening and learning

Always events

Workfo

rce Staffing LeadershipEducation and developmentRoles and Responsibilities

Clinica

l Care

Back to Basics

Developing Clinical Practice

Communication

Care Quality Assurance Framework

Care Compassion Competence Communication Courage Commitment

NHSLA

CQC

All of the nursing and maternity wards and departments have undergone the assessment process. To date 29 out of 33 areas have been awarded accreditation, with focussed work being undertaken in those areas that have not yet achieved all of the standards. If accreditation is not awarded a timescale is agreed with the ward or department manager for a further review, at which point there is an expectation that the standards will be met. There have been a number of benefits from the CQAF process: • Assurance that patients are receiving safe, high quality care • Ward Sisters have ownership of the process through which they can demonstrate leadership. • Opportunities to share good practice – as well as providing healthy competition between

wards/depts. • Provision of ward to board assurance of quality nursing and midwifery care. Moving forward, the standards have been reviewed for 2014, and have been aligned to the CQC key lines of enquiry. The main focus for 2014/15 however will be on sustainability of the standards already achieved, and enable the wards and departments to retain their Care Quality Accreditation status.

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• An action plan has been made for implementing the review’s recommendations. This work has been taken up by the Care in the last few days of life group. The trust will be following national and regional guidance in this area.

• Education sessions on the principles of care in the last few days of life have been held with a number of staff groups. Drop in sessions have also been held.

• Development and distribution of an aide‐memoire card for staff for care in the last few days of life.

• Organisation of a reflective session for consultants and GPs in Gateshead on care in the last few days of life

• Two audits have been undertaken to look at the care in the last few days of life. The first audit has been an internal one and has led to further guidance regarding documentation. The second audit has been the National Care of the Dying audit run by the Royal College of physician. The results of this audit are not available yet.

• A survey has been carried out to look at the views and education needs of general ward staff regarding the Liverpool Care pathway. This work has been showcased in two poster presentations at the Palliative Care Congress 2014.

• Successful bid to employ an end of life care facilitator and Specialist Palliative Care nurse with Macmillan Cancer Care. These two posts will strengthen the team as well as help to further push the end of life care agenda. We are confident of a more responsive team who can support more patients and carers.

• The need for a comprehensive education strategy regarding end of life care has been felt over the last year. We have therefore formed a steering group to look at the educational needs of staff caring for patients and carers at the end of life. The following measures have also been taken : • Establishment of a bi monthly communication skills teaching • Communication skills training to health care assistants and newly qualified nursing staff • Development of palliative and end of life care education for palliative care link nurses • On‐going regular palliative and end of life care education for junior doctors • Development of a Deciding Right teaching programme for all staff • Encouragement of experiential learning with ward staff and student nurses shadowing the

specialist palliative care team • Increasing partnership working with the Gynae‐Oncology team to provide seamless palliative and

end of life care • Development of a ceiling of treatment document

• This has been piloted in two wards • We have also reviewed the quality of our service and self‐assessed against the National Peer

Review standards for Specialist Palliative Care. Caring For Patients with Chronic Obstructive Airways Disease We have undertaken some focused work in COPD services focusing on how well we do in ensuring or patients receive all the important aspects of care at discharge. A baseline assessment undertaken in 2012 showed us that only 39% of our patients admitted with an exacerbation of COPD were receiving all aspects of required care at discharge. As a consequence of this a number of initiatives were introduced to improve this: • Seven day service has been implemented, provided by the respiratory nursing team. • New documentation has been devised to record elements of the COPD bundle which have been

implemented and identify any outstanding elements required. • Our Respiratory Nurses expanded their service to see patients admitted with pneumonia who also

have COPD. • Quarterly audits untaken for 100% of patients admitted with exacerbation of COPD.

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We are pleased to report that this has led to consistent improvement with over 85% of patients admitted with exacerbation of COPD now receiving every aspect of the care bundle. Improving our services for patients with chronic pain The Community Tier 2 Pain Service was set up to respond to the needs of patients who suffer from chronic pain in the community, providing a new type of service that they can access instead of traditional consultant‐led pain services. The clinics are based at Bensham Hospital within the heart of the Gateshead community. We have improved the patient experience and clinical effectiveness by making it easier for patients to access multi‐disciplinary pain services. This includes access to Specialist Pain Physiotherapists, Pain Management Nurse Specialist, Pharmacist and also our Pain Service GP. These professionals offer patients different support options to help manage their pain, for example advice on self‐management strategies to control their long term pain, as well as medication advice and physiotherapy. The development of this service has allowed us to increase the number of new patients we see, waiting times are shorter as patients don’t have to wait to see a consultant. They get more direct access to the care they need, because initial appointments are delivered as a ‘one stop shop’ assessment, so patients get treated without having to wait for different appointments from different health professionals. We also offer an advice line for our current patients so they can call with any queries or problems they may have in‐between appointments which can reduce the need to attend A&E or have repeated GP appointments. Rescuing the Deteriorating Patient The Acute Response Team and the Resuscitation Team work together to deliver positive outcomes for acutely ill patients. In particular the Acute Response Team (ART) provides a consistent approach to the provision of high quality, 24 hour responsive care to acutely unwell patients. The ART team have three key areas of responsibility: responders to rescuing the deteriorating patient, reviewing patients at risk and out of hours’ night site responsibility. In 2013 our efforts continued to primarily rescue patients in the early stages of deterioration to prevent cardiopulmonary arrest, stabilise patients and promote recovery. As a consequence of combined efforts there has been an overall increase in 2222 emergency calls for other medical emergencies leading to a reduction in 2222 calls for cardiopulmonary arrests throughout the Trust.

The National Early Warning Score (NEWS) was introduced to the Trust in June 2013, replacing the Trust modified Early Warning Score charts. A considerable amount of work was undertaken to ensure all staff were trained and competent in using the NEWS charts. The introduction involved a combined competency based training and assessment. Audits undertaken in 2013 identified significant improvement in the

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completion of charts, initial interpretation of observations and initial escalation of care in acutely unwell patients. The NEWS Policy now identifies the role of the Acute Response Team (ART) who respond to medium risk patients as part of the escalation of care. To ensure the ART team have the skills and knowledge to undertake this role effectively at the patients’ bedside significant training is in place. This included a bespoke course ran in conjunction with Sunderland University for all members of ART and staff who regularly support the team. Clinical audit undertaken on the clinical activity of the team demonstrates the success of the team at ward level. Decisions relating to Cardiopulmonary Resuscitation (CPR) have been changed this year with implementation of a regional Deciding Right initiative, including a Do not attempt CPR document. Further work is progressing to introduce advanced decisions to refuse treatment and emergency healthcare plans within the Trust. This initiative aims to improve the decision making process and reduce inappropriate resuscitation attempts. There is on‐going work to improve resuscitation and deteriorating patient training throughout the Trust and to generate a targeted approach to prioritise training to risk. Although improvement has been made with identifying deteriorating patients and referral to further assistance, work will continue to ensure that escalation of care is prompt and appropriate and that decisions relating to resuscitation are carried out in a timely manner.

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3.3 Patient Experience Friends and Family Test We have implemented the Friends and Family Test within inpatient areas, patients attending A&E and more recently in Maternity Services in line with national requirements. This patient experience survey is called the Friends and Family Test because it is based on asking all patients a standard question: “How likely are you to recommend the service to friends and family if they needed similar care or treatment?” The Friends and Family Test provides our patients with another easy way of providing us with direct feedback through asking a very simple question. All patient responses are reviewed and used to ensure we are providing the best possible services to our patients. Before we implemented the test we undertook an exercise asking patients how they would like to be asked the question, for example by text message. They said they would prefer to be given a postcard and consequently this was the method we chose to implement. Inpatients The acute inpatients results for both response rate and net promoter score (NPS) have continued to improve since we implemented the test in April 2013. In March 2014 we achieved a 44.1% response rate and a NPS of 75.2 compared with 8.8% and 73 in April 2013. Results for our inpatient Friends and Family Test from April 2013 to March 2014 are in the table overleaf.

Month Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Inpatient

Net Promoter Score

73.0 71.0 79.0 81.6 83.4 83.6 83.7 81.3 77.1 79.9 77.5 75.2

Inpatient Response Rate %

8.8 9.4 7.3 18.9 32.9 34.4 32.1 33.0 35.0 34.3 34.5 44.1

Through this process patents have left us lots of comments about their care which are fed back to the individual areas. We are now undertaking a review of these to see where we can further improve our patents experience. The word cloud below has been developed from our friends and family test comments. This is a visual representation for text, for quickly identifying the most prominent, frequently used words within a document.

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A&E Department Our Net Promoter Score for A&E has consistently been well above the average for NHS Trusts in England since implementation in April 2013. However, we were disappointed with the response rate we were achieving (5.2% – 7% between April and August 2013) despite local weekly reporting and monitoring of results, visual prompts and staff awareness sessions. The same challenges with the A&E F&FT were being experienced by many Trusts nationally. National results highlight that those Trust achieving the best A&E response rates were using the token methodology. To improve our overall Trust response rate the decision was taken to implement this methodology in our A&E department and since implementation our response rates have improved considerably to 26.9% with a NPS of 66.4 in March 2014. Comment cards are also available in the A&E department to give those patients who want to the opportunity to provide qualitative feedback in response to the question: “If we could change one thing to improve your experience in the A&E today what would that be?” Our results for the A&E Friends and Family Test for the year April 2013 to May 2014 are displayed in the table below.

Month Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar A&E Net Promoter Score

77.8 73.5 61 67.7 66.8 77.3 68.3 66.6 73.4 76.2 74.2 66.4

A&E Response Rate %

5.95 5.59 5.2 7.0 6.6 4.9 30.6 29.6 25.9 18.3 28.3 26.9

Maternity We successfully implemented the F&FT in maternity services in October 2013. This involves asking women the standard question at four touch points in their care: 1. 36 week antenatal appointment 2. Following homebirth or on discharge from delivery suite or birthing unit 3. At discharge from the postnatal ward 4. On discharge from the community post natal midwifery team Our response rates have been variable across the four maternity touch points however we have received consistently good NPS’s. Our NPS’s for the 4 questions in March 2014 were 68.8, 97.3, 96.6 and 76.7. We are also pleased to report that we are now achieving above 20% response rates for all four touch points in the patients pathway. Establishing the eligible patient criteria for this F&FT has been challenging due to patients moving from one provider to another for different parts of their maternity care. This has been recognised as an issue nationally and we are working with NHS England to resolve this. The Friends and Family Test was a nationally mandated CQUIN target for 2013/14 and we are pleased to report that we exceeded the 20% target by Quarter 3. In August we recognised that there was an increase in the number of positive comments that we received naming staff acknowledging the great care they provided. In recognition of this our Director of Nursing, Midwifery and Quality sends a letter of acknowledgment to all staff named by patients positively in F&FT feedback. In addition, every quarter the average net promoter score is calculated and the ward in each division with the highest score celebrate by holding an

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Improvements in Maternity Services This year has been a really exciting time for Gateshead Maternity Services with lots of improvements implemented. We have recently opened the ‘new’ postnatal ward which was designed after really listening to users of our service. Women and their families told us that they wanted a modern, bright ward area that

provides en suite bathrooms, toilets and facilities for other children and the opportunity for partners to use regardless of the type of delivery they had achieved. We created a family room ‘the jungle room’ which gives families the opportunity to spend stress free time together in a room where children can play and adults can enjoy a coffee. In addition we have larger bed spaces and a single room which can support partners staying too. Our families and staff love the new ward and we can now provide quality postnatal care in a family friendly environment.

In 2014 we are planning to improve the facilities for bereaved parents. After listening to the parents of babies that were stillborn we understood one of the hardest things was to leave the unit without their baby especially when others arriving at the unit were celebrating the birth of their baby. We have created a room which has a private external access and parking space for bereaved parents and has been totally renovated to create an environment suitable for these families. In January 2014, Healthcare intelligence expert CHKS has shortlisted 15 NHS Trusts for excellence in

maternity care, as part of its Top Hospitals Programme Awards. This puts the QE Maternity Unit in top 10 per cent of Trusts in the whole country. We were shortlisted following an analysis of nine clinical indicators including caesarean rates, length of stay, complications, readmissions and injuries, as well as three indicators from the Care Quality Commission’s 2013 maternity survey (for English Trusts). Jason Harries, managing director, CHKS said: “These hospital Trusts should be congratulated on reaching the final 15 and for the quality of maternity services that they provide. Finally, from listening to our families we are about to introduce a small thing that will hopefully help our birthing partners; free parking has been arranged for their cars as they arrive to bring our ladies to the unit in labour. Eight bays are being allocated at the front of the unit, to remove the stress and expense at this important time.

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Improving our methods for collecting patient feedback In 2013 we developed and implemented an electronic system using ipads to improve the way we collect real time feedback from our patients. The existing inpatient survey was reviewed and the updated questions aligned to the Chief Nursing Officers 6 Cs: compassion, care, communication, competence, commitment and courage. We have grouped the questions we ask our patients into three domains; communication, care and compassion. The SafeCare facilitators now visit every ward weekly to talk to patients about their experience of care and capture their responses to the survey questions. This new process for gathering feedback from our inpatients has increased the number of responses we have been able to achieve each month from our patients as well as giving us more context and meaning to their responses. Each month our ward managers receive a report containing the results of their feedback from patients. This will enable them to make improvements based on the feedback where appropriate. These reports are displayed on the wards ‘time to care‘ boards along with other key information about patient care. An example of the report is below.

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Our improvement plan based on the results of our survey includes: • Improve written information by re launching the patient hand held information booklet with user

involvement. • Formalise and roll out holistic assessment in all site specific tumour groups. • Improve patient access to Macmillan cancer Information Centre that will also improve benefits

advice for appropriate patients. • To readdress information given to patient in relation to clinical trials/research that will improve

appropriate discussions with patients regarding taking part in cancer research and trials. This is a tremendous achievement for all of our cancer service teams. Listening to concerns and complaints The Trust welcomes and values concerns and complaints from its patients and visitors to ensure we continue to make improvements to our services. Recent national reviews of NHS services e.g. ‘The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry‘(2013) and the ‘A Review of the NHS Hospitals Complaints System, Putting Patients Back in the Picture’ 2013 made recommendations related to improving the complaints process as well as the need for NHS organisations to learn and act on patient comments and complaints. The Trust undertook a quantitative analysis of complaints for the years 2010‐2013 which showed a general upward trend for all clinical departments which was more pronounced for Surgical Services and Women’s Health Services. It also identified an upward trend of complaints related to perceived issues with medical care and demonstrated a consistency over the three years with the perceived issues of communication, staff attitude, discharge and delays in diagnosis and treatment. Whilst this analysis was useful the Trust felt it was necessary to undertake more detailed work to gain a qualitative picture of performance in relation to complaints and identify any potential changes that could be made to: • Improve satisfaction of the complainant following a complaint being dealt with ; • Increase learning from complaints received and identify potential themes that need to be

addressed; and • Improve the Trusts procedure for dealing with and recording complaints

and ultimately improve patient satisfaction. We therefore commissioned the North East Quality Observatory to undertake a qualitative analysis of the Trusts complaints covering 2012/13.

“They have dealt with everything perfectly and I really have great trust in them all, I have had the most wonderful

treatment from the QE Hospital and the NHS”.

“I could not believe the care and respect I had at Gateshead the doctors nurses everyone they were

there for you at all times, I had faith in the surgeons who operated on me I am still alive. And I

thank them from the bottom of my heart”.

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This review concluded that the Trust’s internal procedures for dealing with complaints were largely followed but made some useful recommendations as to how these could be further developed to provide a more robust process. The review also concluded that the Trust generally appeared to be meeting the Patient Association Standards related to handling of complaints. A thematic analysis was also conducted to explore the range of experiences and issues that led to the complaint with the following themes emerging:‐ • A perceived mistake or an error in something that was done or said • A perceived omission (lack of care or concern, options not set out, side effects of treatment not

mentioned) • A perceived inconsistency or discrimination (with reference to another patient or a prior occasion) • A perception of the way in which something was done (inappropriate or insensitive attitude) • A perception that there was an undue delay in an aspect of the service • A misapprehension (misunderstanding about who was who and what their role was) It is of note that proportionally more complaints were made about perceived omissions in services and the manner in which services are delivered than complaints about mistakes or errors. Some analysis of these themes was undertaken by division but no significant relationships were apparent. Building on this important work we held a Complaints Workshop in March 2014 involving key internal and external stakeholders to review the national recommendations made related to complaints and more specifically: • How we can work with outside organisations to ensure that they are involved in the development

and monitoring of our complaints process • How can we ensure that our responses are compassionate, thorough, and don't appear defensive • • Establish what support staff need from our complaints team in dealing with both informal and

formal complaints • How our complaints information could be shared internally, at board level and externally • How could we better support the complainant and their families • Clarify how our duty of candour fit in with the complaints process? Whilst this data is currently being analysed it appears that key areas for future work should include:‐ • Training and support for staff in the handling of complaints • Developing our administrative processes to ensure a consistent and robust approach • Develop mechanisms for more collaborative working with external stakeholders in relation to

complaints • Raising the profile of the Complaints Department Team, their roles and responsibilities and how

they can support staff and complainants The Trust will use all of this valuable information to review its complaints process to ensure that we are responsive to the needs of our patients and visitors and that lessons are learned and processes put in place to improve our outcomes. For the year 2013/14, we received 234 formal complaints, this compares with 243 in 2012/13. During 2013/14 the top five areas of complaints were in relation to aspects of • Communication (96) • Clinical Assessment (Inpatient) (71) • Attitude of staff (63) • Operations and Procedures (43) • Clinical Assessment (Outpatient) (43)

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We take all complaints about our services seriously, they are an important source of information about the quality of our services and how they can be improved. Each formal complaint received is reviewed by the Chief Executive and the Medical Director, is risk assessed, with multi‐disciplinary root cause analysis investigations undertaken for those identified. Each complaint response in signed off by the Chief Executive and Medical Director. Action plans which identify any changes required are completed and signed off by the services. As a result of complaints and concerns over the past year a number of initiatives have been implemented. • Patients are not allowed to be transferred to the discharge lounge without written transfer

documentation being completed as well as a telephone discussion occurring between the two teams to ensure for example notification of next of kin has occurred.

• New guidelines have been introduced for junior doctors regarding patients that are readmitted into the A&E Department and Medical Assessment Area (MAA). This is to ensure that junior medical staff update their direct Consultant on all patients that re‐present to the A&E department and MAA within 72 hours, with plans to extend this to seven days in the future. Additionally, new teaching sessions for junior doctors have been introduced on important diagnoses that can present in unusual ways which will be incorporated into the local induction for new doctors working in the A&E department.

• Develop a teaching session for Junior Doctors within the Orthopaedic Department with regard to Cauda Equina.

• A pilot of a new turn chart was carried out, which also includes prompts to consider use of heel cushions to help prevent pressure ulcers. This is now incorporated in our integrated care monitoring chart.

Complaints Performance Indicators Outturn 2013/14

Complaints received * 234

Acknowledged within 3 working days 234

Complaints closed 210

Closed within agreed timescale 109

Number of complaints well founded# *50

Concerns referred to PALS 786 # Complaints well founded = complaints either fully or significant part upheld. *Total number not yet available.

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Complaints Indicators Outturn 2013/14

Number of closed complaints reopened 24

Number of closed complaints referred to parliamentary ombudsman 3 Outcome of complaints referred to parliamentary ombudsman Outturn 2013/14

Awaiting decision 0

Complaints upheld 1

Complaint referred back for local resolution 0

Declined to be investigated 1

Intervention 0

Outstanding from previous year – upheld 2

Outstanding from previous year ‐ declined 2 Caring for Carers The Trust values the very important work of family and friends caring for people who use our services and we are continually seeking ways to improve our services to this group. We are committed to working in partnership with carers and our local Carer Organisations and improving access to information. We are also committed to supporting staff from the Trust who are carers themselves and ensuring that staff have relevant information regarding where they can access support, this has benefited from partnership working with Gateshead Carers Association. Gateshead Health NHS Foundation Trust as an employer has also signed up to the Carer Friendly Charter which Gateshead Carer Association and provided drop in sessions in the Trust to provide carers with relevant information and support. The Trust also has a Carers group that meets every two months. The aim of the group is to identify ways to improve support for carers and also to identify and support hidden carers who can include Trust employees who also have caring responsibilities. Membership includes local support agencies such as Crossroads and the Gateshead Carers Association and a wide range of Trust staff. Over the past year the group’s work programme has included: • Supporting ‘Carers Week’ through raising awareness with staff, patients and carers of the support

that is available nationally and locally. We held an open event as part of Carers Week 2013, with over 100 people both carers and staff attending the event. This was supported by our local carer Organizations, specialist nurse teams within the Trust including attendance from Local government

• Reviewing facilities available in the Trust and exploring options to develop a comfort room which would be available for carers to freshen up when they are staying with loved ones

• We have developed a poster with access details to local Carer support services based on feedback from carers

• A Carer’s Guide has been developed by the Specialist Nurse in Challenging behaviour, The Person with Dementia and their carers in Gateshead: A Guide to Understanding, Coping and Responding.

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The award is about raising staff awareness of the support that is available to them and to highlight to managers their role in keeping staff fit and healthy at work. David Lane, IIP Assessor, said: “The Trust is an exemplar organisation with a joined‐up approach to health and well‐being, which has embedded into the culture of the organisation. Health and well‐being interventions are innovative and there is a strong infrastructure of support including steering group, champions, occupational health service, ward accreditation and resilience training for staff.” The Trust was complimented on its robust, integrated Health and Well‐being (HWB) Strategy, linked to the vision and values of the Trust, the aims of which are to: • Create a safe and healthy environment and working conditions for staff; • Improve the physical and emotional well‐being of staff; • Encourage and support employees to develop and maintain a healthy lifestyle; • Support people with manageable health conditions or disabilities to maintain access to or regain

work; • Improve the quality of working life for staff; and • Create a healthier, more engaged workforce, thus optimising patient care. Through the HWB Strategy, the Trust has taken an integrated approach to key health priorities, where all available resources are centred upon the common purpose of reducing the incidence of musculo‐skeletal disorders and work‐related stress – the top two causes of sickness absence in the Trust. This holistic approach has enabled five working groups (Safe Working, Caring for You, Mindful Employer, Improving Working Lives and Health Promotion) to contribute in a more co‐ordinated way, leading to more positive outcomes. In the past twelve months activities have included: • April 2013, inaugural Staff Awards ceremony – “Celebrating Our Staff” at the Sage Gateshead; • an increase in Managing Attendance workshops, now mandatory for managers; • Participation in national Walk to Work Week; • annual five‐a‐side football tournament; • October 2013 Health and well‐being Champions engagement event; • Stoptober campaign to quit smoking; • “Movember” competition to raise awareness of male cancers; • Conducted resilience training impact evaluation – 17% improvement in HWB indicated; • Attainment of Investors in People Health and Well‐being Good Practice Award, November 2013; • Christmas Quiz, sponsored by HWB; • Access to holistic therapies on site; • Successful flu vaccination campaign for 63% of staff; • Dry January health promotion campaign; • Mens’ health week supported by Occupational Health visits to departments; • Promoted “Step into Health” free qualification in health, lifestyle and fitness; • Subsidised classes in Zumba and W82Go weight management; • Mindful Employer re‐submission to retain standard in November 2013; • March 2014 Back Care awareness event supported by Clinical ergonomics and Physiotherapy; • Appearance on Look North for exemplary work around staff health and well‐being.

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Listening to our staff through the NHS Staff Survey We continue to participate in the annual staff survey. The Trust’s approach to staff engagement, in terms of the Staff Survey has always been to involve staff and key stakeholders in devising local questions which will provide the organisation with local information. The Trust’s Improving Working Lives (IWL) Working Group, which includes staff representatives, plays a role in monitoring and reporting on staff feedback gained through the survey. The Trust has an open and transparent approach to publicising Trust‐wide and departmental results and acting upon them to improve staff satisfaction and well‐being at work. All NHS Trusts in England are required to take part in the annual National NHS Staff Survey. The survey enables each organisation to benchmark itself against other similar NHS organisations and the NHS as a whole, on a range of measures of staff satisfaction and opinion. This year the Trust agreed to carry out a census of all staff and our response rate is illustrated in the following table.

2012 2013 Trust improvement/ deterioration

Response rate Trust National average Trust National

average

51% 51% 50% 50% Down 1% Measured against 28 Care Quality Commission key indicators, we came out most favourably compared to other acute trusts in the UK in the following areas: 2012 2013 Trust

improvement/ deterioration Top 4 ranking scores Trust National

average Trust National average

% of staff believing the trust provides equal opportunities for career progression or promotion

93% 88% 94% 3.50 1 % increase

% staff feeling pressure in last 3 months to attend work when feeling unwell

23% 29% 22% 28% 1% improvement

% of staff experiencing harassment, bullying or abuse from staff in last 12 months

21% 24% 19% 24% 2% improvement

% of staff suffering work‐related stress in the last 12 months

31% 37% 32% 37% 1% deterioration

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Trust’s lowest four ranked scores were: 2012 2013 Trust

improvement/ deterioration Bottom 4 ranking scores Trust National

average Trust National average

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

88% 89% 88% 91% no change

% of staff appraised in last 12 months 76% 84% 76% 84% no change

staff motivation at work 3.76 3.84 3.75 3.86 0.02 improvement

% staff able to contribute to improvements at work 64% 68% 65% 68% no change

Our ratings show that we are: • In the top 20% of acute Trusts for eight key scores; • Better than average in six key scores; • Average in seven key scores; • Below average in three key scores; • Worst 20% in four key scores.

We have improved on last year’s results in the following areas: • Staff receiving equality and diversity training; • Staff believing the Trust provides equal opportunities for career progression or promotion; • Staff recommending the Trust as a place to work or receive treatment; • Staff feeling satisfied with the quality of work and patient care they are able to deliver; • Work pressure felt by staff; • Support from immediate managers; and • Good communication between senior management and staff. Key priorities for the coming year: • Increase percentage of staff appraisals; • Ensure al managers and leaders are aware of their role in engagement and involvement; • Service improvement to be integrated into day‐to‐day activities; • Continue to implement the Trust’s Health and Well‐being Strategy. The chart below shows the percentage of staff that have completed the national staff survey in 2013 who said they would recommend the Trust to their family or friends who responded agree/ strongly agree compared to other Trusts within the region. Trust Percentage Quartile

Gateshead NHS FT 69.70% 3rd

Sunderland 59.26% 2nd

South Tyneside 63.61% 2nd

Newcastle 87.41% 4th

Northumbria 77.46% 4th Higher is better. 4th Quartile is the top 25% of Trusts

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Our areas for improvement over the coming year include the following Actions Measures How Measure Increase the percentage of staff appraisal and personal development plans

Increase: appraisal job‐related learning and development staff motivation Reduce: intention to leave

NHS Staff Survey Staff turnover

Continue to implement the health and well‐being strategy

Reduce: staff attending work when they are unwell and should be off sick. work related stress harassment and bullying staff working extra hours Improve: work‐life balance morale

NHS Staff Survey

Increase staff engagement and involvement

Increase: motivation communication job satisfaction staff who would recommend the Trust as a place for treatment or care

NHS Staff Survey

Increase service improvement as part of day to day activities

Increase: staff able to contribute to improvements at work staff agreeing that their role makes a difference to patients

NHS Staff Survey

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3.5 Quality overview ‐ performance of Trust against selected indicators In the following sections are a range of quality indicators where the Trust performance can be seen. These further develop the three domains of quality (Patient Safety, Clinical Effectiveness and Patient Experience). The indicators themselves have been extracted from NHS nationally mandated indicators, Commissioning for Quality and Innovation (CQUIN), and locally determined measures. Trust performance is measured against a mixture of locally and nationally agreed targets. The key below provides an explanation of the colour coding used within the data tables.

Target achieved

Although the target was not achieved, it shows either an improvement on previous year or performance is above the national benchmark

Target not achieved but action plans in place

Where applicable, benchmarking has been applied to the indicators using a range of data sources which are detailed in the relevant sections. The Trust recognises that benchmarking is an important attribute that allows the reader to place the Trust performance into context against national and local performance. Where benchmarking has not been possible due to timing and availability of data, the Trust will continue to work with external agencies to develop these in the coming year. 1) Visible Leadership for Safety and Culture Outcomes of Trust Wide MaPSaF Patient Safety Culture Assessment:

2010/11 2011/12 2012/13 2013/2014 Target Pro‐Active / Generative

*No Assessment Undertaken

*No Assessment Undertaken

Pro‐Active Pro‐Active / Generative

MaPSaF Assessment undertaken in May – September 2013 as part of a three year cycle.

Executive Quality and Safety Walkabouts (implemented from February 2010): 2010/11 2011/12 2012/13 2013/14

YTD Target for 2013/14

Cumulative Walkabouts Undertaken 42 33 28 26 48 Average Walkabouts Undertaken per month 3.5 2.8 2.3 2.2 4

Cumulative Actions Identified 101 51 42 49 N/A Cumulative Actions Implemented 77 50 39 46 N/A

Outstanding Actions (more than 60 days old)

15 (85%

completed within 60 days)

0 0 0 90% less than 60 days old

The 3 actions remaining were from the latest walkabouts carried out in February March. Source: Trust Quality Dashboard/Datix

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2) Team Effectiveness / Efficient / Innovative

2008/09 2009/10 2010/11 2011/12 2012/13 2013/4 Target National Benchmark

Mandatory Training Compliance (Percentage take up on allocated places)

59% 55% 64% 67.00% 70.40% 82.4% 90% N/A

Personal Development Plan (PDP) Compliance (Staff with a timely completed PDP)

42.40% 51.90% 48.60% 53.90% 54.00% 77.4% 90% N/A

Staff Sickness and Absence (As reported from personnel)

5.29% 4.96% 4.49% 4.31% 4.70% 5.06% 3.4%

3.95%* (April 2013

– Nov 2013)

Staff Turnover (Labour turnover based of Full Time Equivalent)

12.08% 10.54% 12.44% 10.89% 10.59% 10.62 10% N/A

*The National Benchmark is calculated using the average of the months April to November 2013 and is available from http://www.hscic.gov.uk/catalogue/PUB13841/sick‐abs‐rate‐nhs‐nov‐2013.xlsx

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3) Safe Reliable Care / No Harm A) Reducing Harm from Deterioration:

2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Target National/ Peer

HSMR 97.30 99.86 107.47 111.04 107.80 93.0* <100 100

SHMI

1.05 As expected(Jul 11 ‐ Sep

12)

1.04 As expected(Oct 11‐Sep12)

1.01** As expected(Jun 12‐Jul

13)

As expected or lower than

expected

1.0%

SHMI ‐ Percentage of admitted patients whose treatment included palliative care (contextual indicator)

N/A 0.7%

(Oct 10 ‐ Sep 11)

0.74% (Oct 11‐Sep12)

0.84%*** (Oct 12‐Sep

13) N/A

Risk Adjusted Mortality Index Score taken from CHKS using RAMI 2012 91 82 82 93 90 N/A Ŧ <100

Crude mortality rate taken from CHKS 2.71% 2.68% 2.51% 1.99% 2.09% 1.82% ŦŦ <1.98% N/A

Number of calls to the CRASH team 194 165 180 176 177 200 N/A N/A

Of the calls to the arrest team what percentage were actual cardiac arrests 52.1% 46.7% 48.3% 55.68% 44.06% 37% N/A N/A

Cardiac arrest rate (number of cardiac arrests per 1000 bed days) 0.506 0.390 0.490 0.526 0.46 0.40 N/A N/A

* April 2013‐February 2014 taken from Dr Foster **The national performance is taken from the SHMI June 2012 to July 2013 Executive Summary and can be found on the following website: https://indicators.ic.nhs.uk/webview *** NHS Choices – Clinical Indicators Ŧ this measure is no longer used by the Trust, for Mortality indices the Trust uses HSMR, SHMI ŦŦ Crude Mortality, whilst previously taken from CHKS is now taken from Dr Foster for April 2013 – February 2014.

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B) Reducing Avoidable Harm: 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Target Rate of adverse events per 1000 bed days using the Global Trigger Tool (rate stated is average achieved across all audits undertaken in the year)

23.95 30.99 34.78 20.61 27.72 27.45* N/A

Number of Medication Errors 375 398 305 294 325 344 N/A Medication error – No Harm 311 N/A Medication error – Minimal Harm 28 N/A Medication error – Moderate Harm 5 N/A Medication error ‐ Severe 0 N/A

Hospital Acquired Pressure Damage (grade 2 and above) Not available

54 Sept10 to Mar11

155 295 206 188 Year on year

Reduction

Community Acquired Pressure Damage (grade 2 and above) Not available

Not available 228 587 652 845 N/A

Number of Patient Slips, Trips and Falls 1601 1607 1448 9.9%

reduction 1560 1570 1541 Reduction

(<1308)

Rate of Falls per 1000 bed days 7.63 8.14 8.13 0.12%

reduction 9.18 9.25 8.71 Reduction

(<7.32)

Number of Patient Slips, Trips and Falls Resulting in Harm 840 793 613 22.7%

reduction

457 25.4%

reduction 447 424 Reduction

(420)

Rate of Harm Falls per 1000 bed days 4.00 4.02 3.01 25.1%

reduction

2.69 11%

reduction

2.63 2.2%

reduction

2.40 8.7%

reduction

Reduction (Less than <2.45)

Ratio of Harm to No Harm Falls (i.e. what percentage of falls resulted in Harm being caused to the patient) 52.5% 49.3% 37.1% 29.3% 28.5% 27.5%

Year on Year

reduction Source: Trust incident reporting system Datix * April 2013‐October 2013 after which time this measure was not used

167

2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Target Never Events 0 0 0 1 1 0 0 Total Patient Incidents per 100,000 bed days 2373 2802 2998 3394 3447 3386 N/A

Rate of patient safety incidents resulting in severe harm or death per 100 admissions N/A N/A

0.13 (Oct 10 to Mar 11)

0.11

0.17

0.19 N/A

C) Infection Prevention and Control: 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Target MRSA Bacteraemias apportioned to Acute Trust post 48hrs 16 7 3 2 1 1* 0

MRSA Bacteraemias per 1,000 bed days 0.080 0.035 0.017 0.012 0.006 0.006 Year on year

Reduction Clostridium Difficile Infections post 72hrs – 107 105 48 27 22** 16*** 17

Clostridium Difficile Infections per 10,000 bed days 5.362 5.319 2.702 1.589 1.296 1.23 Year on year

Reduction Uniform Policy 98.0% 99.1% 99.2% 99.3% 98.7% 99.6% 100% Hand Hygiene 96.5% 97.0% 98.6% 98.0% 98.4% 99.6% 100% Intravenous Cannula 85.3% 91.9% 95.2% 94.6% 94.9% 96.8% 100% Indwelling Catheter 91.9% 96.4% 95.6% 94.8% 95.9% 97.8% 100% Equipment Clean and Records Up To Date 97.6% 97.7% 98.6% 98.1% 98.0% 98.6% 100%

*In 2013/14 the Trust had one case of MRSA bacteraemia however; this was as the result of a contaminated specimen not an infection. **In 2012/13 the Trust had 29 cases of Clostridium Difficile, seven cases of Clostridium Difficile were deemed as being unavoidable by an expert appeals panel. This meant that the Trust had a total of 22 avoidable cases of Clostridium Difficile against a trajectory of 21. ***We had 20 cases of Clostridium Difficile, 4 cases of the C. Difficile were deemed as being unavoidable by an expert appeals panel. This meant that the Trust had a total of 16 avoidable cases of Clostridium Difficile against a trajectory of 17.

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4) Right Care, Right Place, Right Time Care of patients following a Stroke:

2008/09 2009/10 2010/11 2011/12 2012/13* 2013/14 Target Benchmark Percentage of patients who spend >90% of time within a dedicated stroke unit 63.60% 78.40% 82.90% 85.30% 89.08%

Apr12‐Feb13 87.27% 80% 84.2Ŧ

Stroke Bundle of 12, percentage of patients who receive bundle of 12 key elements of care N/A N/A

39.10% (when

bundle of 9)

79.00% (when

bundle of 9)N/A 27.13% N/A N/A

Stroke bun

dle of 12 indicators 1. Number of patients scanned within 1 hour of

arrival at hospital. 20% 90.4% 20% 41.7% Ŧ

2. Number of patients scanned within 24 hours of arrival at hospital 85% 91.5% 90% 93.6% Ŧ

3. Number of patients who arrived on stroke bed within 4 hours of hospital arrival (when hospital arrival was out of hours)

59% 81.1% 80% 58.0% Ŧ

4. Number of patients seen by stroke consultant or associate specialist within 24h 84% 81.9% 95% 74.8% Ŧ

5. Number of patients with a known time of onset for stroke symptoms 58% 48.9% 70% 66.1% Ŧ

6. *Number of patients for whom their prognosis /diagnosis was discussed with relative/carer within 72h where applicable 98% 97.3% 95% Not Available

7. Number of patients who had continence plan drawn up within 72h where applicable 94% 97.9% 95% Not Available

8. Number of potentially eligible patients thrombolysed 80% 98.1% 100% 74.7% Ŧ

9. *Bundle 1: Seen by nurse and one therapist within 24h and all relevant therapists within 72h (proxy for NICE QS 5) 48% 64.2% 60% 52.2% Ŧ

10.Bundle 2: Nutrition screening and formal swallow assessment within 72 hours where appropriate 99% 93.6% 95% 93.5% Ŧ

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2008/09 2009/10 2010/11 2011/12 2012/13* 2013/14 Target Benchmark 11.Bundle 3: Patient's first ward of admission was stroke unit and they arrived there within four hours of hospital arrival 68% 74.9% 80% 58.1% Ŧ

12.*Bundle 4: Patient given anti‐platelet within 72h where appropriate and had adequate fluid and nutrition in all 24h periods 69% 87.0% 65% Not Available

Ŧ Source: Sentinel Stroke National Audit Programme October – December 2013 Results https://www.strokeaudit.org/Clinical/Documents.aspx It is to be noted however that the benchmarking data is the latest available and covers a three month period whereas the Trust’s results are for the full year

170

Other Indicators: ** FFCE’s refer to First Finished Consultant Episodes. A patient’s treatment or care is classed as a spell of care. Within this spell can be a number of episodes. An episode refers to part of the treatment or care under a specific consultant, and should the patient be referred to another consultant, this constitutes a new episode.

2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Target Benchmark

Percentage of Cancelled Operations from FFCE’s 0.68% 0.74% 0.50% 0.25% 0.29% 0.68% Improve year on year

1.1%

Patients who return to Theatre within 30 days (Unplanned / Planned / Unrelated) 523 482 556 534 507 540

Improve Year on Year

N/A

Fragility Fracture Neck of Femur operated on within 48hrs of admission / diagnosis n/a 86.8% 91.0% 91.9% 85% 91.72% 90% 85.8%Ŧ

Proportion of patients who are readmitted within 28 days across the Trust 10.58% 10.91% 9.55%. 9.32% 9.42% 8.85%*

Improve year on year

Proportion of patients undergoing knee replacement who are readmitted within 30 days

Not Available 3.99%

4.67% 23 patients readmitted





N/A

Proportion of patients undergoing hip replacement who are readmitted within 30 days

Not Available 4.68%






N/A

NB The proportion of patients assessed for risk of VTE was previously displayed in this section in the Quality Account 2012‐13 but has been removed as it is shown in Section Two. Ŧ This benchmark is taken from the National Hip Fracture Database National Report 2013 Ŧ Ŧ This benchmark is taken from the 2013 Annual Statistical Report of the National Audit of Cardiac Rehabilitation Annual Statistical Report 2013 http://www.cardiacrehabilitation.org.uk/docs/2013.pdf * Dr Foster, year to date as at November 2013

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5) Positive Patient Experience

Inpatients’ Questionnaire (Nov 2013‐March 2014) Domain Score out of a possible 6

Communication 5.76* Care 5.85* Compassion 5.90* Overall composite Score 5.84* * This is an average of scores taken from several questions in each domain. The overall composite score is an average of all scores in the questionnaire. The questionnaire is an updated version of that listed in the section below as shows results Nov 2013‐March 2014

Question 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Target/ Benchmark

Patie

nt Experience Scores**

When the patient reached the ward, did they get enough information about the ward routines, e.g. mealtimes, visiting?

New question in 2011/12 94% 86% 80% 90%

Did the patient receive the information they needed from the staff about their care? n/a 89% Replaced

for 11/12 N/A N/A N/A

Was the patient given enough privacy when discussing their condition or treatment? n/a 91% 90% 99% 98% 95% 90%

Did the patient think the ward/department was nice and clean during their stay/visit to hospital? n/a 94% 94% 98% 95% 97% 90%

Did staff looking after the patient have a caring and compassionate attitude? New question in 2011/12 99% 97% 96% 90%

Were the staff courteous to them and their family /carer? N/A 96% 95% Replaced

for 11/12 N/A N/A N/A

Would the patient recommend the hospital to family and friends? N/A 90% 90% 99% 95% N/A 90%

Overall Patient Experience Trust Score N/A 92% 92% 98% 91% 94% 90%

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Question 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Target/

Benchmark

Respon

sivene

ss to

Inpa

tients’

Person

al Needs #

Was the patient as involved as they wanted to be in decisions about their care and treatment? N/A N/A 51% 58% 61% 60% 56.6%

Did the patient find someone to talk to about their worries and fears? N/A N/A 43% 51% 49% 50% 41.7%

Was the patient told about medication side effects to watch out for? N/A N/A 40% 45% 47% 54% 41.7%

Was the patient told who to contact if they were worried? N/A N/A 80% 81% 83% 83% 80.3%

Was the patient given enough privacy when discussing their condition or treatment? N/A N/A 76% 77% 79% 76% 75%

Overall Composite Score Ŧ N/A N/A 58% 62% 64% 65% 55.1% Complaints ŦŦ 223 206 194 185 243 233 Less than 184

NB Patient Reported Outcome Scores (PROMS) was previously displayed in this section in the Quality Account 2012‐2013, however this information is shown in Section Two. # Information taken from 2013/14 Picker report. **This questionnaire was used from April‐September 2013 Ŧ For the period 2010‐11 – 2012‐13 this score was based on the average of four questions, this has now been updated to include the question “Was the patient given enough privacy when discussing their condition or treatment?” ŦŦ Trust Incident Reporting System: Datix

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6) Safe, Effective Environment, Appropriate Equipment & Supplies 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Target

PLACE assessment – FOOD score Excellent Excellent Excellent Excellent Excellent Publication of data

August 2014 n/a

PLACE assessment – ENVIRONMENT score Excellent Excellent Excellent Excellent Excellent Publication of data

August 2014 n/a

PLACE assessment – PRIVACY and DIGNITY score Excellent Excellent Excellent Excellent Excellent Publication of data

August 2014 n/a

No Harm to Staff – Needle Stick Injury 67 68 94 92 85 54 <50

No Harm to Staff – RIDDOR Reportable Injury 44 43 28 29 23 21 <13

Maximiser Results n/a 98.56% 98.82% 98.7% 98.50% 98.80% 98%

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3.6 National targets and regulatory requirements

No. Indicator Q1 Q2 Q3 Q4 2013/14

YTD 2012/13 Target National Average

1 Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 94.7% 96.6% 94.2% 92.4% 94.3% 96.9% 90% 88.4%

2 Maximum time of 18 weeks from point of referral to treatment in aggregate – non‐admitted

98.2% 97.6% 96.8% 97.0% 97.4% 98.5% 95% 96.8%

3 Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway

94.4% 93.6% 94.6% 94.4% 94.3% 96.3% 92% 94.1%

4 A&E – maximum waiting time of four hours from arrival to admission / transfer / discharge

97.6% 96.0% 95.9% 95.4% 95.2% 95.6% 95% 93.5%

5 All cancers: 62 day wait for first treatment from: urgent GP referral for suspected cancer / NHS Cancer Screening Service referral

87.9% 86.4% 85.2% 80.6% 85.0% 88.6% 85.0% 85.8%**

96.4% 99.4% 94.6% 99.1% 97.4% 98.1% 90.0% 94.7%**

6 All cancers: 31 day wait for second or subsequent treatment, comprising: surgery / anti‐cancer drug treatments / radiotherapy

97.7% 100% 100% 98.1% 98.0% 98.0% 94% 97.3%**

100% 100% 100% 99.4% 99.8% 100% 98% 99.7%**

N/A N/A N/A N/A N/A N/A 94% 97.6%**

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No.

Indicator Q1 Q2 Q3 Q4 2013/14 YTD 2012/13 Target National

Average

7 All cancers: 31 day wait from diagnosis to first treatment 98.0% 99.4% 99.5% 98.5% 98.8% 99.8% 96% 98.2%**

8

Cancer: two week wait from referral to date first seen, comprising: all urgent referrals (cancer suspected) / for symptomatic breast patients (cancer not initially suspected)

92.5% 91.0% 93.1% 93.5 92.6% 94.0% 93% 95.3%**

94.7% 93.5% 97.4% 96.9% 95.7% 95.3% 93% 94.8%**

9

Care Programme Approach (CPA) patients, comprising: receiving follow up contact within seven days of discharge / having formal review within 12 months

100% 100% Nil return* 100% 100% N/A 95% 97.3%**

Nil return* Nil return* Nil return* Nil return* Nil return* Nil return* 95% Not

Available

16 Minimising mental health delayed transfers of care 0% 0% 0% 0% 0% 0% < 7.5% Not

Available

17 Mental health data completeness: identifiers 99.3% 99.3% 99.2% 99.17% 99.3% 99.5% 97% Not Available

18 Mental health data completeness: outcomes for patients on CPA 77.8% Nil return* Nil return* 100% 86.7% 100% 50% Not

Available

19 Certification against compliance with requirements regarding access to health care for people with a learning disability

N/A N/A N/A N/A N/A N/A N/A Not Available

20

Data completeness: community services, comprising: referral to treatment information / referral information / treatment activity information

90.4% 91.8% 92.7% 92.4% 91.8% 92.7% 50% Not Available

100% 100% 100% 100% 100% 95.7% 50% Not Available

100% 100% 100% 100% 100% 92.9% 50% Not Available

Indicators 10‐13 are not applicable. Indicator number 15 (MRSA) of the Compliance Framework 2013/14 was removed on publication of the Risk Assessment Framework August 2013. * There were no qualifying patients for this period. ** These are calculated averages taken from quarterly data published by NHS England http://ww.england.nhs.uk/statistics/statistical‐work‐areas/

176

4. Feedback on our 2013/14 Quality Account This section contains the actual feedback on an earlier Quality Account draft from our local Overview and Scrutiny Committee and Commissioners. 4.1 Gateshead Overview and Scrutiny Committee Draft Statement for inclusion in Gateshead Hospitals NHS Foundation Trust Quality Account Based on Gateshead Healthier Communities OSC’s knowledge of the work of the Trust during 2012‐13 we feel able to comment as follows:‐ Patient Safety – Infection Control The OSC noted the Trust’s good performance in this area and the systems in place to ensure a robust approach to tackling infection control but indicated it was aware of circumstances when containers for hand washing in the hospital were empty. The OSC considered it important the Trust ensures hand washing containers are filled regularly as part of a robust, proactive approach to tackling infection control. The Trust agreed to follow this up. The OSC also sought and received assurances that the Trust has a policy in place to tackle smoking by patients in the hospital as this is an infection control risk and that this is acted on. The Trust also indicated it will be working with Public Health in relation to brief interventions to support patients. The OSC also queried whether the Trust has a policy in relation to wearing of uniforms inside / outside the hospital. The OSC noted that the policy is being reviewed to make it more robust and staff changing areas are planned. Incidents The OSC queried the numbers of incidents of severe harm/death provided in different sections of the account which did not appear to tally and was advised that one set of figures related to all patient safety incidents and the other related to severe harm. The Trust acknowledged changes needed to be made to the account to make this clearer. Clinical Effectiveness – Priority 2 The OSC applauded the Trust’s use of the University of Sterling Dementia Environmental Toolkit as good practice. Patient Reported Outcome Measures The OSC queried why there did not appear to have been any significant shift in the figures for adjusted average health gains in comparison to the England figures. The Trust advised lack of reliable data and low response rates to patient questionnaires was an issue. The OSC was assured the Trust has been putting processes in place to improve response rates and has reinstated access to rehabilitation following some procedures. Patient Experience The OSC previously requested information on complaints upheld and comparative data, including trends in departments / wards over a three year period. The OSC acknowledged that this account did provide some information around themes for one year but was disappointed there was not the level of detail and analysis expected. The OSC noted that the Trust acknowledged the OSC’s comments and indicated an improved system is being developed but this is not quite ready yet. The OSC noted the Trust’s assurances that the plan is to provide more detailed information going forwards.

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4.3 Healthwatch Statement for inclusion in Gateshead Hospitals NHS Foundation Trust Quality Account Healthwatch Gateshead notes the achievements of the Trust throughout the report. Healthwatch Gateshead plans to undertake some focussed work around Hospital Discharge as part of the Healthwatch England Special Inquiry and consider that the evidence from this work should support the Trust to reduce avoidable readmissions to hospital within 30 days of discharge. 4.4 Council of Governors Representative The Governors of Gateshead Health NHS Foundation Trust have been consulted on and involved in the formation of the Trust’s Quality Account in 2013/14. Governors have been continuously involved in refreshing the Trust’s strategic plans with their involvement at various Trust committees and the Council of Governors meetings throughout the year. At each of the Council of Governors meeting during 2013/14, a range of reports have been presented, which enable Governors to receive and discuss quality and patient safety matters and progress against our quality priorities. In January 2014 a Governor workshop was held where Governors were consulted on the quality priorities for inclusion in the Quality Account 2013/14. Overall the Quality Account clearly demonstrates the Trust’s ongoing commitment to delivering high quality and safe patient care and improved health outcomes. Comments received from Governor’s: “The Quality Account 2013/14 reflects the high standards of health care delivered by QE Gateshead, and the hard work, commitment and continuous effort of staff to maintain and improve on those standards. There have been many outstanding achievements this year”.

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The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2013/14;

the content of the Quality Report is not inconsistent with internal and external sources of information including:

Board minutes and papers for the period April 2013 to May 2014

Papers relating to Quality reported to the board over the period April 2013 to May 2014

Feedback from the commissioners dated 23/05/14

Feedback from governors dated 21/5/2014

Feedback from Local Healthwatch organisations dated 23/5/14

The trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 05/5/2014;

The 2013 national patient survey dated 2014

The 2013 national staff survey dated 2014

The Head of Internal Audit’s annual opinion over the trust’s control environment dated 15/5/2014

CQC quality and risk profiles dated 31/3/13

CQC Intelligent monitoring report dated 13/3/14

the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered;

the performance information reported in the Quality Report is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice;

the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) (published at www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor.gov.uk/annualreportingmanual)).

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the board

Mrs J E A Hickey, Chairman Date: 21/05/2014

Mr ID Renwick, Chief Executive Date: 21/05/2014

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Glossary of Terms Antimicrobial Is an agent that kills micro‐organisms or inhibits their growth. Antimicrobial medicines can be grouped according to the micro‐organisms they act against. For example, antibacterials are used against bacteria and antifungals are used against fungi. Board of Directors A board of directors is a body of elected or appointed members who jointly oversee the activities of an organisation. Care Quality Commission (CQC) The CQC is the independent regulator of all health and adult social care in England. The aim being to make sure better care is provided for everyone, whether that’s in hospital, in care homes, in peoples’ own homes, or elsewhere. Commissioning for Quality and Innovation (CQUIN) The CQUIN framework was introduced in April 2009 as a national framework for locally agreed quality improvement schemes. It enables commissioners to reward excellence by linking a proportion of English healthcare provider’s income to achievement of local quality improvement goals. Commissioners These are responsible for ensuring that adequate services are available for their local population by assessing need and purchasing services. Clinical Audit Clinical audit measures the quality of care and service against agreed standards and suggests or makes improvements where necessary. Clostridium Difficile (C.Diff) Clostridium difficile is a bacterium that occurs naturally in the gut of two‐thirds of children and 3% of adults. It does not cause any harm in healthy people, however some antibiotics can lead to an imbalance of bacteria in the gut and then the Clostridium difficile can multiply and produce toxins that may cause symptoms including diarrhoea and fever. This is most likely to happen to patients over 65. The majority of patients make a full recovery however, in rare occasions it can become life threatening. Datix Datix is an electronic risk management software system which promotes the reporting of incidents by allowing anyone with access to the trust Intranet to report directly into the software on easy‐to‐use web pages. The system allows incident forms to be completed electronically by all staff. Department of Health (DOH) The Department of Health is a department of the UK government with responsibility for government policy in England on health, social care and the NHS. Dignity Dignity is concerned with how people feel, think and behave in relation to the worth or value that they place on themselves and others. To treat someone with dignity is to respect them as a valued person, taking into account their individual views and beliefs. Diabetic Ketoacidosis Diabetic ketoacidosis is a dangerous complication of diabetes mellitus in which the chemical balance of the body becomes far too acidic.

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Healthcare Quality Improvement Partnership The Healthcare Quality Improvement Partnership (HQIP) was established in April 2008 to promote quality in healthcare, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. Hospital Standard Mortality Ratio (HSMR) The HMSR is an indicator of healthcare quality that measure whether the death rate at a hospital is higher or lower than would be expected. Foundation Doctors A Foundation Doctor (FY1 or FY2) is a grade of medical practitioner in the United Kingdom undertaking the Foundation Programme which is a two‐year, general postgraduate medical training programme which forms the bridge between medical school and specialist/general practice training. The grade of Foundation Doctor has replaced the traditional grades of Pre‐registration House Officer and Senior House Officer. Foundation Trust A Foundation Trust is a type of NHS organisation with greater accountability and freedom to manage themselves. They remain within the NHS overall, and provide the same services as traditional trusts, but have more freedom to set local goals. Staff and members of the public can join the board or become members. Healthcare‐ associated infection This is an avoidable infection that occurs as a result of the healthcare that a person receives. Healthwatch Healthwatch are local like minded individuals and organisations who share a commitment to improvement and learning and a desire to improve services for local people local. Hospital Episode Statistics (HES) This is a data warehouse containing a vast amount of information on the NHS, including details of all admissions to NHS hospitals and outpatient appointments in England. HES is an authoritative source used for healthcare analysis by the NHS, Government and many other organisations. Joint Consultative Committee This is a group of people who represent the management and employees of an organisation, and who meet for formal discussions before decisions are taken which affect the employees. Meticillin‐ Resistant Staphylococcus Aureus (MRSA) MRSA is a bacterium responsible for several difficult to treat infections in humans. MRSA is, by definition, any strain of staphylococcus aureus bacteria that has developed resistance to antibiotics including penicillins and cephalosporins. It is especially prevalent in hospitals, as patients with open wounds, invasive devices and weakened immune systems are at greater risk of infection than the general public. Monitor Monitor is the sector regulator for Health Services in England. Established in January 2004 to authorise and regulate NHS Foundation Trusts it is independent of central government and directly accountable to parliament. National Confidential Enquiries These are enquiries which seek to improve health and healthcare by collecting evidence on aspects of care, identifying any shortfalls in this, and disseminating recommendations based on these findings. Examples include Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK (MMBRACE) and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

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National Confidential Enquiry into Patient Outcome and Death (NCEPOD) NCEPOD's purpose is to assist in maintaining and improving standards of medical and surgical care for the benefit of the public by reviewing the management of patients. This is done by undertaking confidential surveys and research, and by maintaining and improving the quality of patient care and by publishing and generally making available the results. National Institute for Health and Clinical Excellence (NICE) The National Institute for Health and Clinical Excellence provides guidance, sets quality standards and manages a national database to improve people’s heath and prevent and treat ill health. It makes recommendations to the NHS on new and existing medicines, treatments and procedures, and on treating and caring for people with specific diseases and conditions. It also makes recommendations to the NHS, local authorities and other organisations in the public, private, voluntary and community sectors on how to improve people’s health and prevent illness. National Patient Survey The NHS patient survey programme systematically gathers the views of patients about the care they have recently received because listening to patients' views is essential to providing a patient‐centred health service. National Patient Safety Agency (NPSA) The National Patient Safety Agency promotes improved, safe patient care by informing, supporting and influencing the health sector. It is an arm’s length body of the Department of Health, established in 2001 with a mandate to identify patient safety issues and find appropriate solutions. National Health Service Litigation Authority (NHSLA) The NHSLA is a special health authority responsible for handling negligence claims made against NHS bodies. It also aims to raise safety standards and reduce the number of negligent or preventable incidents through its risk management programme. Overview and Scrutiny Committee Overview and Scrutiny Committees in local authorities have statutory roles and powers to review local health services. They have been instrumental in helping to plan services and bring about change. They bring democratic accountability into healthcare decision‐making and make the NHS more responsive to local communities. Patient Advice and Liaison Service (PALS) PALS is an impartial service designed to ensure that the NHS listens to patients, their relatives, their carers and friends answering their questions and resolving their concerns as quickly as possible. Plan, Do, Study, Act (PDSA) cycles Plan, do, study, act (PDSA) cycles are used to test an idea by temporarily trialling a change and assessing its impact. The four stages of the PDSA cycle are: Plan ‐ the change to be tested or implemented Do ‐ carry out the test or change Study ‐ data before and after the change and reflect on what was learned Act ‐ plan the next change cycle or full implementation Picker Institute Picker Institute is a non‐profit organisation that works with patients, professionals and policy makers to promote a patient centred approach to care. It uses surveys, focus groups and other methods to gain a greater understanding of patients’ needs. It is a world leader focusing on the measurement of the patient experience and recognised as an important source of information, advice and support.

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Pressure Ulcers Pressure ulcers are also known as pressure sores or bed sores. They occur when the skin and underlying tissue becomes damaged. In very serious cases the underlying muscle and bone can also be damaged. Research Clinical research and clinical trials are an everyday part of the NHS and are often conducted by medical professionals who see patients. A clinical trial is a particular type of research that tests one treatment against another. It may involve patients, people in good health or both. Risk The potential that a chosen action or activity (including the choice of inaction) will lead to a loss or an undesirable outcome. Risk assessment This is an important step in protecting patients and staff. It is a careful examination of what could cause harm so that we can weigh up if we have taken enough precautions or should do more to prevent harm. Root Cause Analysis This is a technique that helps us to understand why something has occurred in the first place. The learning is then shared with staff across the hospital to inform our practice and help prevent further reoccurrence. Secondary Use Services‐ SUS A system designed to provide management and clinical information based on a anonymous set of clinical data. Special Review A special review is carried out by the Care Quality Commission. Each special review looks at themes in health and social care. They focus on services, pathways and care groups of people. A review will usually result in assessments by the CQC of local health and social care organisations as well as supporting the identification of national findings. Trust Board The Trust Board is accountable for setting the strategic direction of the trust, monitoring performance against objectives, ensuring high standards of corporate governance and helping to promote links between the trust and the community. The Chair and Non‐Executive Directors are lay people drawn from the local community and are accountable to the Secretary of State. The Chief executive is responsible for ensuring that the board is empowered to govern the organisation and to deliver its objectives.

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Appendix A: Participation in National Clinical Audits and National Confidential Enquiries Gateshead Health NHS Foundation Trust’s participation in National Clinical Audits for which it was eligible to participate in during 2013/14:

Name of Audit Trust participating % of case submission

Acute Adult Critical Care (Case Mix Programme – ICNARC)

Yes 1047 – no minimum requirement

Emergency Use of Oxygen Yes 18 – no minimum requirement National Audit of Seizures in Hospitals (NASH) No ‐ National Emergency Laparotomy Audit (NELA) Yes Data collection up to November 2014 Joint Registry (NCAPOP) Yes 1,512 – no minimum requirement Paracetamol overdose (care provided in emergency departments)

Yes 100% (50/50)

Severe Sepsis and Septic Shock Yes 40% (20/50) Severe Trauma (TARN) Yes 93% (165/178) Blood and Transplant Patient Information & Consent Yes 100% (24/24) Red Cell Issue Yes Data collection up to May 2014 Cancer Bowel Cancer (NCAPOP) Yes 146 – no minimum requirement Lung Cancer(NCAPOP) Yes 183 – no minimum requirement Oesophago‐gastric Cancer (NCAPOP) Yes 50 – no minimum requirement Heart Acute myocardial infarction and Acute Coronary Syndrome (MINAP) (NCAPOP)

Yes 306*

Cardiac Rhythm Management Yes 100 – no minimum requirement Heart Failure (NCAPOP) Yes 386 – no minimum requirement National Cardiac Arrest Audit (NCAA) Yes 74 – no minimum requirement National Vascular Registry Yes 29 – no minimum requirement – Long term conditions National Diabetes Inpatient Audit – Adult (NADIA)


Diabetes audit – Paediatric Yes 358 – no minimum requirement Inflammatory Bowel Disease (IBD) Yes 17 – no minimum requirement National Chronic Obstructive Pulmonary Disease (COPD)

Yes Data submission up to 31 May 2014

Rheumatoid and early inflammatory arthritis Yes Data submission commences Feb 2014 and continues for 3 years

Older people Falls and Fragility Fractures Audit Programme – National Hip Fracture Database


Sentinel Stroke National Audit Programme (SSNAP)

Yes 90%

Other Elective Surgery (PROMS)

Yes 72% (968/1337)

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Name of Audit Trust participating % of case submission

Women & Children’s Child Health Programme (CHP‐UK) No ‐

Epilepsy 12 audit (Childhood epilepsy) – Round 2


Moderate or Severe Asthma in Children Yes

82% (41/50)

Neonatal intensive & special care (NCAPOP) Yes 224 – no minimum required (data period 01.01.13‐31.12.13)

Paediatric asthma Yes 13 – no minimum requirement *to be validated

The Trust was not eligible to take part in the National Audit listed below by the Department of Health as we do not provide these services:‐ CABG and valvular surgery (Adult Cardiac Surgery Audit) Coronary Angioplasty (NICOR Adult Cardiac Interventions Audit) Head & Neck Cancer (DAHNO) National Audit of Schizophrenia (NAS) Paediatric Bronchiectasis Paediatric Cardiac Surgery (NICOR Congenital Heart Disease Audit)_ Paediatric Intensive Care (PICNet) Prescribing in Mental Health Services (POMH) Pulmonary Hypertension Renal Replacement Therapy (Renal Registry) The Trust has taken part in the following National Audits additional to the list provided by the Department of Health:‐ Carotid Endarterectomy Heavy Menstrual Bleeding IMPRESS: An International Single Day Point Prevalence Study for Severe Sepsis And/Or Septic Shock National Care of the Dying Audit – Round 4 National Potential Donor Audit 2013 Royal College of Obstetricians and Gynaecologists Audit on practice to prevent early onset Neonatal Group B Streptococcal Disease The Medical Emergency Team – Hospital Outcomes After a Day – METHOD Study Gateshead Health NHS Foundation Trust participation in National Confidential Enquiries 2013/14:

Name of Enquiry Trust participating % of requirement NCEPOD – Lower Limb Amputation Yes Study on going NCEPOD – Tracheostomy Care Yes 100% (9/9) NCEPOD – Subarachnoid Haemorrhage Yes 100% (3/3) NCEPOD – Alcohol Related Liver Disease Yes 100% (3/3) MMBRACE ‐ Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK

Yes 33% (4/12)*

NCISH – National Confidential Inquiry into Suicide and Homicide

Yes Nil return as no eligible patients during 2013/14

*of the 8 outstanding cases, it is anticipated that the data will be submitted by the deadline of the end of May 2014

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Appendix B: Independent Auditor’s Report to the Board of Governors of Gateshead Health NHS Foundation Trust on the Quality Report We have been engaged by the Council of Governors of Gateshead Health NHS Foundation Trust (“the Trust”) to perform an independent assurance engagement in respect of Gateshead Health NHS Foundation Trust’s Quality Report for the year ended 31 March 2014 (the “Quality Report”) and certain performance indicators contained therein. Scope and subject matter The indicators for the year ended 31 March 2014 subject to limited assurance consist of the national priority indicators as mandated by Monitor: • Clostridium Difficile – all cases of Clostridium Difficile positive diarrhoea in patients aged two years

or over that are attributed to the Trust. • 62 Day cancer waits – the percentage of patients treated within 62 days of referral from GP. We refer to these national priority indicators collectively as the “indicators”. Respective responsibilities of the Directors and auditors The Trust’s Directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: • the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS

Foundation Trust Annual Reporting Manual; • the Quality Report is not consistent in all material respects with the sources specified in Monitor’s

2012/13 Detailed Guidance for External Assurance on Quality Reports; and • the indicators in the Quality Report identified as having been the subject of limited assurance in the

Quality Report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Detailed Guidance for External Assurance on Quality Reports;

We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Report and consider whether it is materially inconsistent with: • Board minutes for the period April 2013 to May 2014. • Papers relating to Quality reported to the Board over the period April 2013 to May 2014. • Feedback from the Commissioners dated May 2014. • Feedback from local Healthwatch organisations dated May 2014. • The Trust’s complaints report published under regulation 18 of the Local Authority Social Services

and NHS Complaints Regulations 2009, 2013/14. • The 2013/14 national patient survey. • The 2013/14 national staff survey. • Care Quality Commission quality and risk profiles/intelligent monitoring reports 2013/14. • The 2013/14 Head of Internal Audit’s annual opinion over the Trust’s control environment. We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the “documents”). Our responsibilities do not extend to any other information.

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We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. This report, including the conclusion, has been prepared solely for the Council of Governors of Gateshead Health NHS Foundation Trust as a body, to assist the Council of Governors in reporting Gateshead Health NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2014, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and Gateshead Health NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included: • Evaluating the design and implementation of the key processes and controls for managing and

reporting the indicators. • Making enquiries of management. • Testing key management controls. • Limited testing, on a selective basis, of the data used to calculate the indicator back to supporting

documentation. • Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the

categories reported in the Quality Report. • Reading the documents. A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non‐financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual. The scope of our assurance work has not included governance over quality or non‐mandated indicators which have been determined locally by Gateshead Health NHS Foundation Trust. Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2014: • the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS

Foundation Trust Annual Reporting Manual;

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• the Quality Report is not consistent in all material respects with the sources specified above; and • the indicators in the Quality Report subject to limited assurance have not been reasonably stated in

all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual. KPMG LLP Chartered Accountants Quayside House 110 Quayside Newcastle upon Tyne NE1 3DX 30 May 2014

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Independent Auditor’s Report to the Council of Governors of Gateshead Health NHS Foundation Trust

We have audited the financial statements of Gateshead Health NHS Foundation Trust for the year ended 31 March 2014 on pages 208 to 252. These financial statements have been prepared under applicable law and the NHS Foundation Trust Annual Reporting Manual 2013/14. This report is mode solely to the Council of Governors of Gateshead Health NHS Foundation Trust in accordance with Schedule 10 of the National Health Service Act 2006. Our audit work has been undertaken so that we might state to the Council of Governors of the Trust, as a body, those matters we are required to state to them in an auditor’s report and for no other purposes. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors of the Trust, as a body, for our audit work, for this report or fort he opinions we have formed. Respective responsibilities of the accounting officer and the auditor As described more fully in the Statement of Accounting Officer’s Responsibilities on page 191 the accounting office is responsible for the preparation of financial statements which give a true and fair view. Our responsibility is to audit, and express an opinion on, the financial statements in accordance with applicable law and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practice’s Board’s Ethical Standards for Auditors. Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of whether the accounting policies are appropriate to the Trust’s circumstances and have been consistently applied and adequately, disclosed the reasonableness of significant accounting estimates made by the accounting officer and the overall presentation of the financial statements. In addition we read all the financial and non‐financial information in the annual report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report. Opinion on financial statements In our opinion the financial statements: • give a true and fair view of the state of the Group’s and the Trust’s affairs as at 31 March 2014 and

of the Group’s and Trust’s income and expenditure for the year then ended; and

• have been prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2013/14.

Opinion on other matters prescribed by the Audit Code for NHS Foundation Trusts In our opinion the information given in the Strategic and Directors’ Report for the financial year for which the financial statements are prepared is consistent with the financial statements.

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Matters on which we are required to report by exception We have nothing to report where under the Audit Code for NHS Foundation Trusts we are required to report to you if, in our opinion, the Annual Governance Statement does not reflect the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual, is misleading or is not consistent with our knowledge of the Trust and other information of which we are aware from our audit of the financial statements. We are not required to assess, nor have we assessed, whether all risks and controls have been addressed by the Annual Governance Statement or that risks are satisfactorily addressed by internal controls. Certificate We certify that we have completed the audit of the accounts of Gateshead Health NHS Foundation Trust in accordance with the requirements of Chapter 5 of Part 2 of the National Health Service Act 2006 and the Audit Code for NHS Foundation Trusts issued by Monitor. Paul Moran, for and on behalf of KPMG LLP, Statutory Auditor Chartered Accountants Quayside House 110 Quayside Newcastle upon Tyne NE1 3DX Independent Auditor’s Report to the Board of Gateshead Health NHS Foundation Trust on the NHS Foundation Trust Consolidation Schedules We have examined the NHS foundation trust consolidation schedules (FTCs) number FTC01 to FTC41X of Gateshead Health NHS Foundation Trust for the year ended 31 March 2014, which have been prepared by the Director of Finance and acknowledged by the Chief Executive. This report is made solely to the Board of Gateshead Health NHS Foundation Trust in accordance with paragraph 24(5) of Schedule 7 of the National Health Service Act 2006 (the Act) and for no other purpose. In our opinion the consolidation schedules are consistent with the statutory financial statements on which we have issued an unqualified opinion. Paul Moran, for and on behalf of KPMG LLP, Statutory Auditor Chartered Accountants Quayside House 110 Quayside Newcastle upon Tyne NE1 3DX 29 May 2014

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Annual Governance Statement Scope of Responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum The Purpose of the System of Internal Control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Gateshead Health NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Gateshead Health NHS Foundation Trust for the year ended 31 March 2014 and up to the date of approval of the annual report and accounts. Capacity to Handle Risk As Accounting Officer and Chief Executive, I have overall responsibility for ensuring that there are effective risk management and integrated governance systems in place in the Trust and for meeting all statutory requirements and to adhering to guidance issued by Monitor in respect of governance and risk management. The leadership and accountability arrangements for the Chief Executive Officer, Board of Directors, Business Unit Associate Directors, Business Unit Service Line Managers, Clinical Leads, Heads of Service and staff are set out in the Trust’s Risk Management Policy. In addition there are clear terms of reference for the Board sub committees, including the Patient, Quality, Risk & Safety (PQRS) Committee, which is the co‐ordinating committee for risk. Good practice in risk management, both within the Trust and nationally, is shared across the organisation through Divisional SafeCare (Clinical Governance in Gateshead Health NHS foundation Trust) events, Trust wide SafeCare events, SafeCare Alerts, SafeCare Good Practice Bulletins and reports to the PQRS Committee and the Board. The Risk and Control Framework Risks are proactively identified through the systematic process of risk identification and risk assessment, which includes both internal and external sources of information. Internal sources include extensive monitoring maintained through compliance with NHS Litigation Authority (NHSLA) Level 3 Risk Management Standards for Acute Trusts and also Level 3 compliance with the NHSLA’s Clinical Negligence Scheme for Trusts (CNST) Risk Management Standards for Maternity Services. Following the formal withdrawal of the NHS Litigation Authority Risk Management Standards and assessment processes for acute trusts and maternity services, the Trust has continued to monitor all relevant areas as part of the embedded and effective monitoring and risk systems. Work is currently being undertaken, to ensure that there is further targeted work to address claims risks and to focus on learning lessons and to further improve patient safety. Monitoring is being updated to focus on outcomes rather than processes and will

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facilitate identification of actions to more directly improve patient outcomes. Internal information and external data from the NHSLA Extranet will be used to assist in the improvements. Internal and external reactive sources of risk identification used include the analysis of incident data, complaints and claims information, national reports or enquiries and national alert systems. All risks are evaluated using a risk assessment matrix. Risk registers are used throughout the Trust to record all relevant information including the description of the risk, initial, current and residual risk scores, actions to formulate a summary risk treatment plan and review date. High scoring risks that threaten achievement of corporate priorities and objectives are proactively identified and formulate the Board Assurance Framework. The Board Assurance Framework is reviewed by the Trust Board every quarter. A three‐year programme has been devised with Internal Audit who review and report on control, governance and risk management processes to assist with assurance. Any reports which do not provide full assurance have issues of note and an action plan in place with a target date set until all actions are completed. Our incident reporting system is used as a key way of managing risks which have not been identified proactively and could or have resulted in harm. An open reporting culture is promoted and supported throughout the organisation. To ensure that the Trust measures the safety of the organisation in relation to reporting and learning from incidents and in line with the Francis Report (2013) recommendations, the Trust undertakes an assessment of its safety culture using the Manchester Patient Safety Framework (MAPSAF) self‐assessment tool every three years and, from this, Trust and Divisional action plans are developed. This assessment was undertaken in 2013/14. By minimising risks, the Trust, through the risk assessment process, seeks to protect the quality of services provided, reduce harm, maximise the resources available for patient services and care and protect the Trust’s reputation. The Trust aims to be proactive in its approach to the management of risk and will endeavour to identify, control, and where possible eliminate the risk before incidents of actual loss or harm have occurred. For this approach to be effective and for risk management to be embedded into the organisation it is recognised that there must also be the following key elements: • A live and meaningful organisation‐wide corporate Board Assurance Framework. • Ongoing risk management awareness raising. • A well‐founded risk register. • Involvement/participation of all staff. • Integration of risk management into operational management. • Active local risk management policies and processes. • Clearly communicated arrangements/designated responsibilities for risk management. • Training in risk assessment. • Training and compliance with ‘Being Open’ and ‘Duty of Candour’. • A robust integrated incident reporting system. • Development of risk management within a fair and just culture. The Trust’s approach following adverse

incidents focuses on “what went wrong” not “who went wrong”. • Sound clinical practice which is evidence based and undertaken by appropriately skilled and equipped

staff in accordance with policies, procedures and guidelines. • Effective communication within and between Business Units, Wards, and Departments and also with

patients, the public, and stakeholders. • Safe systems of work and safe practices which are undertaken in accordance with up‐to‐date policies,

procedures, and guidelines which are known and understood and complied with by the staff concerned.

• Proactive management of complaints and claims.

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• Ongoing monitoring of actions/controls put in place to minimise the organisation’s risk exposure for all risks identified from the Risk Register, incidents, complaints and claims.

The Audit Committee performs a key role in reviewing and monitoring the systems of internal control. The Committee receives regular reports on the work and findings of the internal and external auditors and provides assurance to the Board following each meeting via minutes. The Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission (CQC). Compliance with the CQC Essential standards of quality and safety has been monitored through the implementation of a new electronic system ‘Health Assure’. The aim is to ensure a comprehensive approach to self‐assessment through the completion of provider compliance assessments for each of the 16 essential standards of quality and safety. An executive director has been allocated to each of the quality and safety outcomes, supported by corporate and business unit outcome leads. Gateshead Health NHS Foundation Trust is required to register with the CQC and its current registration status is registered without conditions. The CQC has not taken enforcement action against Gateshead Health NHS Foundation Trust during 2013/14. Gateshead Health NHS Foundation Trust has participated in CQC reviews but no CQC investigations during the reporting period. The CQC made two unannounced visits during 2013/14 to carry out routine Mental Health Act monitoring visits of detention in hospitals. The first visit was carried out in July 2013 and covered Ward 23. The second visit covered “detention in hospital for acute admissions” and involved the Trust’s Cragside Court Unit. The visit reports raised three and four action points respectively, which were minor and completed within two months. Overall, there were no compliance issues. The CQC undertook an unannounced planned review of compliance on 4th and 5th December 2013 to observe and check how people were being cared for at each stage of their treatment and care. The CQC visited the accident and emergency department, the medical assessment unit and the associated wards 3, 23, 24 and 25.The report concluded that the patient feedback during the inspection was universally positive and all standards inspected had been met. This included the categories of:

• care and welfare of people who use services, • safeguarding people who use services from abuse, • supporting workers, • complaints.

There are robust arrangements in place to provide assurance on the quality of performance information. The Trust has a robust governance structure in place to oversee the management of information risks. Four sub groups have been established and are responsible for collating all identified information risks pertaining to Data Protection and Confidentiality, Records Management, Data Quality and Secondary Use and Systems Management and Development, and are responsible for maintaining the organisation's Information Governance Risk Log. The Health Informatics Assurance Committee, a sub group of the Business and Service Development Committee is responsible for communicating identified Information Management and Technology (IM&T) risks and their assessed impacts on the organisation and suggested mitigation. The effectiveness of governance structures The Trust has a robust governance structure in place which is routinely subject to review.

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This includes a comprehensive Board committee structure which encompasses assurance on: • Business and Service Development, • Patients, Quality, Risk and Safety, • Finance, • Human Resources, • Audit, • Remuneration and Mental Health committees.

and a framework of “feeder” sub‐committees. In the next twelve months the Trust plans to undertake an internal review of this established structure and will also in due course consider Monitor’s proposals for an external review. The Trust introduced the new Board Assurance Framework in 2012 which has subsequently been audited and is subject to continuous improvement. This includes detailed reports on strategic priorities and associated risks at quarterly intervals. In 2013 the Trust reviewed its Senior Management structure and this was reduced from four clinical divisions to three Business Units to be led by an Associate Director who is also part of the Central Executive Team. Associate Directors are non‐voting members of the Board. The new Associate Director posts are accountable to the Board for delivery of services to patients and financial sustainability within the Business Units. To support this line of accountability a new performance management infrastructure has been established which includes management meetings (Board to Board meetings) and performance agreements that will enable the Trust to roll out robust service line management in line with delivery of its Strategic Transformation and Improvement Programme. The responsibilities of Directors and Committees All Directors both executive and associate have a clear portfolio of responsibilities and areas for which they are accountable. Some areas of risk are delegated to the Trust’s Executive Directors:

• the Medical Director is responsible for clinical audit, • the Medical Director and Director of Nursing, Midwifery and Quality are responsible for clinical

governance, infection prevention and control and patient safety, • the Director of Nursing, Midwifery and Quality is the Chair of the PQRS Committee to ensure that a

fully integrated and joined up system of risk and control management is in place on behalf of the Board,

• the Director of Finance is the strategic lead for financial risk and the effective co‐ordination of financial controls throughout the Trust. He is also responsible for Information Technology, Health Records and Information Governance risks and

• the Director of Estates and Facilities is responsible for emergency preparedness. The Trust has a strong, effective Board comprising seven Non‐Executive Directors, six Executive Directors (including the Chief Executive) and the Trust Chairman. An annual appraisal process is in place to ensure knowledge and skills of Board members continue to reflect the strategic needs of the organisation and roles and responsibilities of Board members. The Trust recognises the need for its Board to respond to changing external circumstances and the composition contains an appropriate balance of clinical and management leadership skills and experience, key requirements for the successful delivery of the forward plan. The Trust has appointed the Vice Chairman of the Trust as the Senior Independent Director to be available to governors and members if they have concerns, which contact through the normal channels of Chairman, Chief Executive or Deputy Chief Executive has failed to resolve or for which such contact is inappropriate.

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The Board regularly undertakes an internal collective assessment of its performance and provides feedback on leadership by the Chairman. Non‐Executive Directors are appointed for an initial tenure of up to three years following which re‐appointment processes apply. Induction training is provided for new Board members and separate time out events are held to provide a forum for strategic debate and to broaden understanding of key issues impacting upon the Trust’s delivery of objectives. Reporting lines and accountabilities between the Board, its committees and the Executive team There are clear terms of reference for each Board committee and its subsequent sub Committees and the role of directors are clarified. Clear reporting lines are in place for all of the Board committees and each committee has both Executive and Non‐Executive members. Issues are discussed in detail at the relevant Board committee and significant issues raised to Board level, with regular Board reports on: Quality, Risk, Finance, Clinical and Corporate Governance, Capital and Strategy. Levels of delegation are in place and are reported in the Corporate Governance Manual, Reservation and Delegation of Powers, Trust Constitution and the Risk Management Policy. The submission of timely and accurate information to assess risks to compliance with the Trust’s licence and the degree and rigour of oversight the Board has over the Trust’s performance The Board of Directors meets regularly. Board agendas and papers are made available to all Governors and Governors receive regular information on Clinical and Corporate Governance, Performance, Finance, Quality and Patient Safety. The Board agenda is balanced and focuses on:

• Strategy and current performance • Finance, quality and risk • Making decisions and receiving information • Matters internal to the organisation and external stakeholders

On an annual basis the Trust Board is required to identify a number of corporate objectives as of key strategic importance to the Trust and incorporating national and local priorities. Delivery of the corporate objectives are set out in a Board Assurance Framework. The contents of the prioritised Board Risk Register and Board Assurance Framework are considered by the Board every three months to ensure that the elements are still relevant, up to date and to ensure actions are undertaken to reduce the risk to the residual score in a timely manner. The Board Assurance Framework identifies and monitors risks that may potentially compromise the organisation’s ability to meet its strategic objectives. The document is developed through input from the Executive Directors and senior managers and is informed by the risk register. The Trust has a protocol in place to ensure all new policies are considered as to whether an equality impact assessment is required prior to approval, and to ensure equality impact assessments are published. The Trust is a member of a regional NHS Equality group and works in partnership to share resources and best practice. The Trust uses the national NHS Equality Delivery System to rate equality performance and identify objectives. This was completed with the involvement of members of the local community and other stakeholders, (NHS, local government, Healthwatch and the voluntary sector). Full details of this process including the consultation and involvement, is published on the Trust website: http://www.qegateshead.nhs.uk/edhr

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The Trust published a new Equality Strategy (2013‐16) in April 2013 and published an annual equality report in April 2014. The Trust has a Patient Carer and Public Involvement Group with a remit to co‐ordinate patient, carer and public involvement activity throughout the organisation and to ensure best practice and latest research is shared between wards and departments. Membership is made up of representatives from across the organisation and beyond and part of its remit is to consider how to inform and involve members of the public in relation to the management of risks which may affect them. Going forward the Patient Carer and Public Involvement Group is amalgamating with the Patient Experience and dignity sub‐group and will be named the Patient Involvement and Experience Group. 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 into the Scheme are in accordance with the scheme rules and that member Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The foundation trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on the UKCIP 2009 weather projects, to ensure that this organisation’s obligations under the Climate Change Act and the Adaption Reporting requirements are complied with. The Annual Governance statement for 2012/13 identified the following areas as Future clinical and non clinical risks. Update on 2013/14 Major Clinical Risks

• Failure to achieve Clostridium Difficile (CDI) reduction. The Trust had a trajectory of 17 for CDI. For the year 2013/14 there were 20 cases, however 4 appeals were upheld. The National CDI Objective for 2014/15 indicates a case management objective for Gateshead of 24 cases which, based upon on historical performance and the stringent management approach previously described, is deemed achievable.

• Winter Bed pressures. To mitigate this risk the Trust used ‘Lean’ methodology to undertake a Trust

wide project to support all inpatient wards with efficient, effective discharge planning including the setting up of a discharge lounge.

• Potential for the Efficiency Programme to have an impact on the quality of services being delivered.

The Trust has Maintained level 3 (highest level) with the NHSLA and achieved Band 6 (highest possible, lowest risk) with CQC.

• Risk to quality and safety in a time of transition. To mitigate this risk the Trust has developed

excellent partnership arrangements with external teams particularly our clinical commissioning group.

• Impact of seven day working. The Deputy Chief Executive and Medical Director are leading a piece

of work in conjunction with the Business Units and Associate Directors to develop a strategy for seven day working in line with the Keogh paper ‘NHS services – open seven days a week: every day counts.’

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Update on 2013/14 Major Non Clinical Risks

• Patient Administration System (PAS) replacement system. To mitigate this risk the Trust has an established programme of internal data quality reviews, focussed its PAS development and training on data quality and validation issues and commissioned independent audit work of its key performance information. This is in the process of being reviewed by Internal Audit and external consultants.

• Trust wide ownership of the efficiency programme and consideration of the failure to deliver the efficiency target. To mitigate these risks project board arrangements have been put in place with an executive lead. Reports of progress are updated at the monthly Senior Management Team and the appropriate committee of the Trust Board. The Board receives regular updates on the non clinical risks via the Board Assurance Framework, supplementary reports and business cases. £6.7m was achieved, in total (i.e. including recurrent and non recurrent elements).

• Extensive estate development within the Gateshead Health NHS Foundation Trust site which may impact on patients using the Trust for their treatment and care. The building of the Trust’s new Emergency Care Centre has commenced and the project remains on target to open in 2014.

Future Clinical Risks for 2014/15 • Winter Pressures which may impact on the high quality service we provide. To mitigate this risk the

Trust actively participates with partner agencies and commissioners in the urgent care network. Experience gained from this is being built upon with strategic improvements to effective discharge and patient flow at ward level which will have positive impact in the future. The Trust has sought external support from the Emergency Care Intensive Support Team (ECIST) to review Trust–wide emergency care provision. The Trust also holds a winter review session and lessons learned are factored into future winter planning to build in resilience and manage risk. The Trust will continue to work closely with partner organisations to mitigate any risks going forward in our 2014/15 winter planning programme.

• Efficiency Programme, which has the potential to impact on the quality of services being delivered. To

mitigate this risk all initiatives are assessed for risk to quality of service delivery and financial risk on non‐delivery. This is managed through the Trust’s performance (Board to Board) meetings which are attended by the Associate Directors and managers from each Business Unit and the Executive Directors of the Trust. The Project Management Office (PMO) ensures that all key projects are impact assessed for risk to quality and finance. Quality metrics have been applied to service redesign and this is presented monthly at the Transformation Board and quarterly to the Board.

• 62 day wait cancer waiting times target The Trust failed this indicator in Quarter Four (2013/14) and early indications are that the Quarter One (2014/15) target is under significant pressure. To mitigate this risk the Trust has produced a stringent and comprehensive Trust wide action plan which is reviewed and updated at the Achieving the Target meetings and Board to Board meetings and also at Network level as this target is a pressure both regionally and nationally.

• Impact of seven day working. The Deputy Chief Executive and Medical Director are leading a piece of

work in conjunction with the Business Units and Associate Directors to develop a strategy for seven day working in line with the Keogh paper “NHS services – open seven days a week: every day counts”.

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Future Non Clinical Risks 2014/15 • The Trust replaced its Patient Administration System (PAS) in July 2012. As expected, and as reported in

last year’s governance statement, with a project of this size and complexity there have been a range of subsequent issues around performance reports and data quality. Development of the system continues to be managed through robust project board arrangements and there are additional data quality validation processes in place which have been exposed to external scrutiny.

To manage the risks the Trust has restructured the management arrangements in its informatics functions and is in the process of recruiting a new Deputy Director for Informatics and a new Head of Information. The Trust will also continue with independent audit work of its key performance information, the programme of internal data quality reviews; and with its PAS development and training on data quality and validation issues.

• Trust wide ownership of the Efficiency Programme. To mitigate this risk the Trust has project board

arrangements in place with an executive lead. There is an established system whereby monthly reports are presented to the Senior Management Team via a verbal update and the Finance Committee of the Trust Board. The Board receives regular updates via the Board Assurance Framework. To promote trust–wide ownership and implement the change necessary to deliver on system‐wide improvement and efficiency the Trust has established a Strategic Transformation Improvement Programme. Some of the improvement work streams going forward are:

• new Emergency Care Build, • outpatient productivity and • theatre productivity.

The Medical Director and Director of Nursing and Quality for the Trust meet quarterly with the Clinical Commissioning Group to assure them that quality and safety are not compromised by cost reduction initiatives. The Trust also has in place bi‐monthly quality assurance meetings with the Clinical Commissioning Group, where there is detailed analysis and discussion regarding quality and risk issues.

• Extensive estate development within the Gateshead Health NHS Foundation Trust Site which may impact on patients choosing Gateshead Trust for their treatment and care.

The Trust undertakes Patient Led Assessments of the Care Environment (PLACE) reviews, developing a ’Fresh Eyes’ approach to customer care involving all departments taking responsibility to look at their areas through the eyes of the customers. The Trust has developed the ‘15 steps challenge’ which provides a series of questions and prompts to guide patients, service users, carers and NHS staff through their first impressions of a care setting to help to gain an understanding of how patients and service users feel about the care provided and what gives them confidence.

Review of Economy, Efficiency and Effectiveness of the Use of Resources During 2013/14 the Trust’s overall financial performance was monitored and managed on a regular basis by the Trust’s Senior Management Team, the Finance Committee, the Business and Service Development Committee, the Business & Efficiency Programme Board and the Board of Directors. The Board, supported by its Finance Committee, reviews all aspects of financial performance of the Trust in detail on a monthly basis. The Finance Committee has responsibility for the monitoring of financial risks for the organisation and, during 2013/14, undertook a self‐assessment review of compliance against its duties and responsibilities. The outcome was very positive and resulted in an updated and more robust Terms of Reference for the committee.

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The Trust had an efficiency target of £8.4m in 2013/14. Of the target, £6.7m was delivered through recurrent and non‐recurrent measures. The Trust has a good record of accomplishment in identifying and delivering efficiency and cost reduction programmes, however this is proving to be increasingly challenging year on year. This, together with on‐going success in attracting new work to the organisation, has contributed to a strong financial performance. The Trust is constantly monitoring its underlying cost base, and has made significant progress during 2013/14 in the quality of Reference Cost, Patient Level Costing & Information Service and Service Line Reporting (SLR) information to help underpin this scrutiny. However, the Trust has been unable to implement SLR as quickly as it would have liked but it is scheduled to be implemented in 2014/15. The Trust undertakes extensive monitoring with its partners including, Dr Foster, The Foundation Trust Network and McKinsey. The Audit Committee continues to review how further developments can be made in the way in which the necessary assurances on internal control systems can be made. The changes made in 2011/12 in the planning of Internal Audit work and the format of the corporate objectives has proved critical in enabling Internal Audit to link its assurance work to the objectives of the Trust ensuring all significant areas of risk are covered during the three year planning cycle. The 2013/14 plan was based around outcomes, and the reporting of assurances against the strategic objectives of the Trust to provide a more robust framework for the receipt of assurances. The Trust also participates in initiatives to ensure value for money, as an example, it subscribes to the NHS Foundation Trust Network Benchmarking organisation that provides comparative information analysis on productivity, clinical and quality indicators for high risk specialties. The Trust also maintained NHS Litigation Authority Risk Management Standards Level 3 in both General and Maternity standards (highest levels). Annual Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of Annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. The Quality Report represents a balanced view and there are appropriate controls in place to ensure the accuracy of the data. There has been extensive engagement with staff and service users, governors and external stakeholders to gain their views and identify priorities for the 2014/15 quality report. The themes were considered by the Board of Directors and the key priorities agreed. During the course of this year the Trust has had regular meetings with commissioners to monitor progress against the Commissioning for Quality and Innovation (CQUIN) indicators. The Trust has put controls in place to ensure the accuracy of the Quality Account. The list below is not exhaustive but includes: ∙ IG01 ‐ Information Governance Strategy, ∙ RM 04 ‐ Incident Reporting and Investigating, ∙ RM 21 ‐ Complaints Policy and ∙ IG05 ‐ Records Management Policy. The Trust has for the last four years requested an independent audit from the Northern Internal Audit and Fraud Service specifically around Information Security and the Information Governance (IG) Toolkit to gain significant assurance that the processes that are in place provide sufficient evidence that information risks are adequately assessed and addressed by the Trust. The Trust meets compliance with the standards for the IG toolkit submission with all controls achieving a minimum of Level 2 and 87% compliance within the 45 controls for Acute Trusts and was graded as Satisfactory (Green) in 2013/14.

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There are robust clinical governance processes in place that cover clinical audit, compliance with national guidance such as that published by National Institute for Health and Care Excellence (NICE). The Trust has an extensive range of clinical governance policies and these are reviewed at appropriate intervals. The Trust’s Quality and Safety Dashboard links ward level measures of quality and safety up to Business Unit and Board metrics. The Trust continues to use Business Units performance reports, governance and quality reports and has been working with the North East Quality Observatory and the Foundation Trust Network to use a range of benchmarking opportunities to give additional scrutiny to quality processes with individual services. The Clinical Audit Strategy and Policy give a clear framework for the delivery of clinical audit and is managed through the Clinical Audit Committee and reported to the Board on an annual basis. The Trust recognises that the delivery of high quality and respectful care is dependent upon a skilled and effective workforce. The Quality Account contains a distinct section, ‘Focus on Staff’ that illustrates the Trust’s commitment to and investment in staff development, their health and wellbeing and the importance of listening and responding to staff views. The Trust has robust policies for the recruitment and development of staff and this is reflected in the quarterly Human Resources (HR) Trust Board report. Mandatory training and appraisal is a key performance indicator and is reported in the Board Quality Dashboard on a monthly basis. The Trust continues to perform well in the national staff survey. Review of Effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the NHS foundation trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and othr reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit Committee, Patient Quality Risk and Safety Committee and a plan to address weaknesses and ensure continuous improvements of the systems is in place. The Board has reviewed the CQC Intelligent Monitoring report against the 16 essential Standards of Quality and Safety. The Trust will use the Dr Foster Care Quality Tracker module as an early warning system for any negative changes in the data. The Trust currently maintains its NHS Litigation Authority Level 3 for both Trust wide risk management and maternity services. The NHSLA has formally withdrawn the risk management scheme from 31 March 2013. The trust remains committed to the processes established that ensures that extensive monitoring of risk is undertaken and actions are identified and completed to ensure that improvements are made to improve patient and staff safety and that the risk of litigation is minimised. The Audit Committee continues to oversee the maintenance of an effective system of internal control. The Patient Quality Risk and Safety Committee ensures that a fully integrated approach is taken when considering whether the Trust has in place systems and processes for the delivery of high quality, patient focused care. Clinical audit work is valued as a method of providing assurance and is set into an annual plan to reflect priorities identified by local and national agendas. The Clinical Audit Committee ensures that there are effective systems and processes in place to enable healthcare professionals to participate in clinical audit, that clinical audit is being used appropriately to evaluate compliance with national clinical guidance, that the Trust is participating in relevant national audits and that clinical audit is leading to measurable benefits for patients.

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Appendix to Annual Governance Statement

HEAD OF INTERNAL AUDIT OPINION ON THE EFFECTIVENESS OF THE SYSTEM OF INTERNAL CONTROL AT GATESHEAD HEALTH NHS FOUNDATION TRUST FOR THE PERIOD ENDED 31st MARCH 2014

Roles and responsibilities The whole Board is collectively accountable for maintaining a sound system of internal control and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system. The Annual Governance Statement (AGS) is an annual statement by the Accountable Officer, on behalf of the Board, setting out: • how the individual responsibilities of the Accountable Officer are discharged with regard to maintaining a

sound system of internal control that supports the achievement of policies, aims and objectives; • the purpose of the system of internal control as evidenced by a description of the risk management and

review processes, including the Assurance Framework process; • the conduct and results of the review of the effectiveness of the system of internal control including any

disclosures of significant control failures together with assurances that actions are or will be taken where appropriate to address issues arising.

The organisation’s Assurance Framework should bring together all of the evidence required to support the AGS requirements. In accordance with Public Sector Internal Audit Standards, the Head of Internal Audit (HoIA) is required to provide an annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes (i.e. the organisation’s system of internal control). This is achieved through a risk‐based plan of work, agreed with management and approved by the Audit Committee, which should provide a reasonable level of assurance, subject to the inherent limitations described below. The opinion does not imply that Internal Audit have reviewed all risks and assurances relating to the organisation. The opinion is substantially derived from the conduct of risk‐based plans generated from a robust and organisation‐led Assurance Framework. As such, it is one component that the Board takes into account in making its AGS. The Head of Internal Audit Opinion The purpose of my annual HoIA Opinion is to contribute to the assurances available to the Accountable Officer and the Board which underpin the Board’s own assessment of the effectiveness of the organisation’s system of internal control. This Opinion will in turn assist the Board in the completion of its AGS, and may also be taken into account by the Care Quality Commission. My opinion is set out as follows: 1. Overall opinion; 2. Basis for the opinion; 3. Commentary. My overall opinion is that significant assurance can be given that there is a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls, put the achievement of particular objectives at risk.

206

The basis for forming my opinion is as follows:

1. An assessment of the design and operation of the underpinning Assurance Framework and supporting processes; and

2. An assessment of the range of individual opinions arising from risk‐based audit assignments, contained

within internal audit risk‐based plans that have been reported throughout the year. This assessment has taken account of the relative materiality of these areas and management’s progress in respect of addressing control weaknesses.

3. Reliance that is being placed upon third party assurances.

The commentary below provides the context for my opinion and together with the opinion should be read in its entirety. The design and operation of the Assurance Framework and associated processes. The review of the Trust’s Assurance Framework is a critical piece of work on the central methodology through which the Trust conducts its review of the system of internal control.

• There are limited links between the framework and the Trust’s clinical audit programme. Further work is required to ensure that any clinical audits undertaken provide assurance to the Trust.

• In some instances the positive assurances included against key controls have simply referred to

information reported to the Board and are not assurance that the controls are operating effectively.

• The positive assurances included against some key controls do not indicate the date of the assurance. As such it is not possible to establish in which financial year the assurances were provided. Whilst it is for the Board to decide if these assurances remain relevant this cannot be done without inclusion of the date of the assurance.

• Trust policies are not always shown as key controls for some principal risks. As such the positive

assurances provided by the audit monitoring tools and key performance indicators contained within the policies are not shown as a source of assurance.

Management have commented that they intend to take actions in the coming year to address these issues. It is for the Board to decide whether the framework contains all of the assurance it needs and whether the assurances in the framework are sufficient. The range of individual opinions arising from risk‐based audit assignments, contained within risk‐based plans that have been reported throughout the year. The opinions as shown in the table below were derived from work carried out in line with the Audit Committee approved Audit Plan. Internal Audit derived the 2013/2014 Plan from a number of sources; these include the Trusts own Assurance Framework, Internal Audit risk assessment and coverage of areas that External Audit would seek to place reliance on Internal Audit’s work. Management had direct input to the audit risk assessment process to ensure accurate targeting of limited audit resources to the priority areas for the Trust. Audit areas determined from the risk assessment process, which do not yet appear in the Trusts Assurance Framework, were considered for inclusion in the Audit Plan. A number of discussions were also held with management to determine key areas of risk for the year and these were incorporated into the Plan.

207

Where issues of note have been raised or limited assurance has been given on individual audits, this has not affected my overall opinion as management responded positively to the reports and has agreed remedial action to address the findings raised, or the areas under review were not deemed to be high risk to the Trust, or were not material systems.

LAURETTA MCEVOY DIRECTOR OF INTERNAL AUDIT

208

Statement of Comprehensive Income for the year ended 31 March 2014

Group Foundation

Trust Group Foundation

Trust 2013/14 2013/14 2012/13 2012/13

Note £000 £000 £000 £000 Revenue Operating Income from continuing operations 2 203,426 202,874 190,683 190,425Operating Expenses of continuing operations 3 (216,768) (216,425) (184,592) (184,426)Operating surplus / (deficit) (13,342) (13,551) 6,091 5,999Finance Costs Finance income 5 125 77 291 243Finance expense ‐ financial liabilities 6.1 (662) (662) (203) (203)Finance expense ‐ unwinding of discount on provisions 15 (49) (49) (64) (64)PDC Dividends payable (2,775) (2,775) (3,254) (3,254)Net Finance Costs (3,361) (3,409) (3,230) (3,278)Surplus / (Deficit) from continuing operations (16,703) (16,960) 2,861 2,721Surplus / (Deficit) for the financial year (16,703) (16,960) 2,861 2,721Other comprehensive income Impairments 0 0 (277) (277)Revaluations 8.7 (10,996) (10,996) 19 19Asset disposals 0 0 0 0Share of comprehensive income from associates and joint ventures 0 0 0 0Movements arising from classifying non current assets as Assets Held for Sale 0 0 0 0Fair Value gains/(losses) on Available‐for‐sale financial investments 0 0 0 0Recycling gains/(losses) on Available‐for‐sale financial investments 0 0 0 0Other recognised gains and losses 0 0 0 0Actuarial gains/(losses) on defined benefit pension schemes 0 0 0 0Other reserve movements 23 0 (145) (264)Total Comprehensive Income for the year (27,676) (27,956) 2,458 2,199

The notes on pages 213 to 252 form part of these accounts.

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210

Statement of changes in Taxpayer’s Equity

Group

Total

Public Dividend Capital

Revaluation Reserve

Charitable Fund

Reserve Other

Reserves

Income and Expenditure Reserve

£000 £000 £000 £000 £000 £000 Taxpayers' Equity at 1 April 2013 120,012 103,927 16,830 1,661 99 (2,505) Changes in taxpayers' equity for 2013/14 Retained surplus/(deficit) for the year (16,703) n/a n/a 195 n/a (16,898) Impairments 0 n/a 0 n/a 0 n/aTransfer from Revaluation Reserve to I & E reserve 0 n/a 0 n/a n/a 0 Revaluations Property,Plant and Equipment (8,631) n/a (8,631) n/a n/a n/a Asset disposals 0 n/a (88) n/a n/a 88Other reserve movements 23 0 0 5 0 17

94,701 103,927 8,111 1,861 99 (19,297) Public Dividend Capital received 7,692 7,692 n/a n/a n/a n/aPublic Dividend Capital repaid 0 0 n/a n/a n/a n/aTaxpayers' Equity at 31 March 2014 102,393 111,619 8,111 1,861 99 (19,297)

Total


Revaluation Reserve

Charitable Fund

Reserve Other

Reserves


£000 £000 £000 £000 £000 £000 Taxpayers' Equity at 1 April 2012 111,732 99,515 17,352 0 99 (5,234) Prior Period Adjustment 1,409 0 0 1,409 0 0Taxpayers' Equity at 1 April 2012 Restated 113,141 99,515 17,352 1,409 99 (5,234)

Changes in taxpayers' equity for 2011/12 Retained surplus/(deficit) for the year 2,861 0 0 140 0 2,721Impairments (277) n/a (277) n/a n/a n/aRevaluations Property, Plant and Equipment 19 n/a 19 n/a n/a n/a Asset disposals 0 n/a 0 n/a n/a 0Other reserve movements (145) 0 (264) 119 0 0Other reserve movements CF consolidation 0 n/a n/a (8) n/a 8 115,600 99,515 16,830 1,661 99 (2,505) Public Dividend Capital received 4,412 4,412 n/a n/a n/a n/aPublic Dividend Capital repaid 0 0 n/a n/a n/a n/aTaxpayers' Equity at 31 March 2013 120,012 103,927 16,830 1,661 99 (2,505)

211

Statement of changes in Taxpayer’s Equity

Foundation Trust

Total


Revaluation Reserve

Other Reserves


£000 £000 £000 £000 £000Taxpayers' Equity at 1 April 2013 118,343 103,927 16,830 99 (2,513) Changes in taxpayers' equity for 2013/14 Retained (deficit) / surplus for the year (16,960) n/a n/a n/a (16,960) Impairments 0 n/a 0 n/a n/aRevaluations Property,Plant and Equipment (8,631) n/a (8,631) n/a n/aAsset disposals 0 n/a (88) n/a 88

92,752 103,927 8,111 99 (19,385)Public Dividend Capital received 7,692 7,692 n/a n/a n/aPublic Dividend Capital repaid 0 0 n/a n/a n/aTaxpayers' Equity at 31 March 2014 100,444 111,619 8,111 99 (19,385)

Total


Revaluation Reserve

Other Reserves


£000 £000 £000 £000 £000 Taxpayers' Equity at 1 April 2012 111,732 99,515 17,352 99 (5,234)Taxpayers' Equity at 1 April 2012 Restated 111,732 99,515 17,352 99 (5,234)Changes in taxpayers' equity for 2011/12 Retained surplus/(deficit) for the year 2,721 0 0 0 2,721Impairments (277) n/a (277) n/a n/aRevaluations Property,Plant and Equipment 19 n/a 19 n/a n/aAsset disposals 0 n/a 0 n/a 0Other reserve movements (264) 0 (264) 0 0Other reserve movements CF consolidation 0 n/a n/a n/a n/a

113,931 99,515 16,830 99 (2,513)Public Dividend Capital received 4,412 4,412 n/a n/a n/aTaxpayers' Equity at 31 March 2013 118,343 103,927 16,830 99 (2,513)

212

Statement of Cashflows for the year ended 31 March 2014

Group Foundation


Trust 2013/14 2013/14 2012/13 2012/13

Note £000 £000 £000 £000Cash flows from operating activities Operating (deficit) / surplus from continuing operations (13,342) (13,551) 6,091 5,999

(13,342) (13,551) 6,091 5,999Non‐cash income and expense:Depreciation and amortisation 8.1 4,287 4,287 5,455 5,455Impairment 16,150 16,150 1,087 1,087Reversals of Impairments (184) (184) (291) (291)Gains on disposal of fixed assets (290) (290) (213) (213)Non Cash Donations credited to Income (47) (47) (126) (126)Decrease / (Increase) in Trade and Other Receivables (5,429) (5,405) 578 578Increase in Inventories (196) (196) (3) (3)Increase in Trade and other Payables 550 509 1,303 1,303Decrease in Other Liabilities (882) (882) (1,610) (1,610)Increase / (Decrease) in Provisions 193 193 (560) (560)Tax (paid) /received 0 0 0 0Other movements in operating cash flows (52) 45 56 64NHS Charitable Funds ‐ working Capital adjustments 0 0 (22) 0Net cash inflows from operating activities 759 629 11,745 11,683Cash flows from investing activities Interest received 125 77 243 243Purchase of Property, Plant and Equipment (29,322) (29,322) (14,985) (14,985)Proceeds from Sales of Property, Plant and Equipment 376 376 0 0NHS Charitable Funds ‐ net cash flow from investing activities (50) 0 120 0Net cash outflow from investing activities (28,871) (28,869) (14,622) (14,742)

Net cash (outflow) / inflow before financing (28,112) (28,240) (2,877) (3,059)Cash flows from financing activities Public dividend capital received 7,692 7,692 4,412 4,412Public dividend capital repaid 0 0 0 0NHS Charitable funds ‐ net cash flows from financing activities 0 0 0 0

Loans received from Foundation Trust Financing Facility 17,400 17,400 2,600 2,600Capital element of finance lease rental payments (78) (78) (103) (103)Other capital receipts 0 0 0 0Interest paid (621) (621) (146) (146)Interest element of finance lease (41) (41) (58) (58)PDC Dividend paid (2,774) (2,774) (3,254) (3,254)Cash flows from other financing activities 0 0 0 0Net cash inflow / (outflow) from financing activities 21,578 21,578 3,451 3,451Increase in cash and cash equivalents (6,534) (6,662) 574 392Opening Cash and Cash equivalents at 1 April 21,538 21,215 20,964 20,823Closing Cash and Cash equivalents at 31 March 12 15,004 14,553 21,538 21,215

213

Notes to Accounts Note 1. Accounting Policies Accounting policies and other information Monitor has directed that the financial statements of NHS Foundation Trusts shall meet the accounting requirements of the NHS Foundation Trust Annual Reporting Manual which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the 2013/14 NHS Foundation Trust Annual Reporting Manual issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury’s Financial Reporting Manual to the extent that they are meaningful and appropriate to NHS Foundation Trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts. Accounting convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property. Critical judgements in applying accounting policies The following are the critical judgements, apart from those involving estimations (see below) that management has made in the process of applying the Trust’s accounting policies and that have the most significant effect on the amounts recognised in the financial statements. To fully comply with the reporting requirements under Modern Equivalent Accounting (MEA), information had been received from DTZ Limited (now DTZ UGL) covering the asset valuation at 1st April 2013. This has resulted in a net charge of £23,907,224 being a reduction in the value of fixed assets as a result of the exercise. During 2013/14 the FT has continued with its asset verification programme and as a consequence disposals in the year have accounted for the removal of £1.9 m of gross asset cost. The net book value (NBV) of these disposals was £86k. The annual impairment review accounted for £304k of assets taken to the Statement of Comprehensive Income. Estimated asset lives have been provided by DTZ UGL Limited and component accounting introduced based on an assessment of average weighted elemental lives. All leases and contractual arrangements held by the Trust have been reviewed to assess compliance with International Accounting Standard 17 ‐ Leases. The majority of arrangements were determined to be operating leases, although some have been classified as finance leases following the detailed review of lease terms, economic asset lives and termination arrangements. Key sources of judgements and estimation uncertainty In the application of the Trust’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods. An accrual for untaken annual leave, by staff, is included in these financial statements. Provisions have been calculated in accordance with IAS37 and are separated into current and non‐current amounts. Where the time value of money is material future cash flows have been discounted using rates published by HM Treasury. Consolidation The following standards and interpretations have been adopted during 2013/14:‐ The NHS foundation trust is the corporate trustee to Gateshead Health NHS Foundation Trust Charitable Funds (‘the Charity’), charity reference number 108614. The foundation trust has assessed its relationship to the charitable fund and determined it to be a subsidiary because the foundation trust has the power to govern the

214

financial and operating policies of the charitable fund so as to obtain benefits from its activities for itself, its patients or its staff. Prior to 2013/14, the FT ARM permitted the NHS foundation trust not to consolidate the charitable fund. From 2013/14, the foundation trust has consolidated the charitable fund and has applied this as a change in accounting policy.The charitable fund’s statutory accounts are prepared to 31 March in accordance with the UK Charities Statement of Recommended Practice (SORP) which is based on UK Generally Accepted Accounting Principles (UK GAAP). On consolidation, necessary adjustments are made to the charity’s assets, liabilities and transactions to: • recognise and measure them in accordance with the foundation trust’s accounting policies; and • eliminate intra‐group transactions, balances, gains and losses. IAS 8 Accounting Policies, Changes in Accounting Estimates and Errors is applied in selecting and applying accounting policies, accounting for changes in estimates and reflecting corrections of prior period errors. The FT has ensured that the consolidation of the charitable fund accounts has complied with the standard and associated policies regarding restatement and presentation. Prior Period Adjustments IAS 8 Accounting Policies has been followed in the disclosure of a prior period adjustment to allow the consolidation of the charitable fund accounts in the financial year 2013/14. This has resulted in a restatement against the 1st April 2012 balances within the Statement of Changes in Taxpayer's Equity Income Income in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at the fair value of the income received. The main source of income for the Trust is contracts with commissioners in respect of healthcare services. Where income is received for a specific activity which is to be delivered in a future financial year that income is deferred. Income from the sale of non‐current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract. Expenditure on Employee Benefits Short‐term Employee Benefits Salaries and employment‐related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry‐forward leave into the following period. Pension costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows:

215

Accounting Valuation A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period. Actuarial assessments are undertaken in intervening years between formal valuations using updated membership data and are accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2014, is based on the valuation data as 31 March 2013, updated to 31 March 2014 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used. The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pension Accounts, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office. Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates. The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2004. Consequently, a formal actuarial valuation would have been due for the year ending 31 March 2008. However, formal actuarial valuations for unfunded public service schemes were suspended by HM Treasury on value for money grounds while consideration is given to recent changes to public service pensions, and while future scheme terms are developed as part of the reforms to public service pension provision due in 2015. The Scheme Regulations were changed to allow contribution rates to be set by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and appropriate employee and employer representatives as deemed appropriate. The next formal valuation to be used for funding purposes will be carried out at as at March 2012 and will be used to inform the contribution rates to be used from 1 April 2015. Scheme provisions The NHS Pension Scheme provides defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained: The Scheme is a “final salary” scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service. With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new provision is known as “pension commutation”. Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year. From 2011‐12 the Consumer Price Index (CPI) will be used to replace the Retail Prices Index (RPI). Early payment of a pension, with enhancement, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year’s pensionable pay for death in service, and five times their annual pension for death after retirement is payable. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the employer.

216

Members can purchase additional service in the NHS Scheme and contribute to money purchase AVC’s run by the Scheme’s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers. Expenditure on goods and services Expenditure on goods and services is recognised when, and to the extent that, they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non‐current asset such as property, plant and equipment. Property, Plant and Equipment Recognition Property, plant and equipment is capitalised where: • it is held for use in delivering services or for administrative purposes; • it is probable that future economic benefits will flow to, or service potential be provided to, the Trust; • it is expected to be used for more than one financial year; and • the cost of the item can be measured reliably; and • assets individually have a cost of at least £5000, or form a group of assets that initially have a cost of

more than £250 and collectively a cost of at least £5000, where the assets are functionally interdependent, they have simultaneous purchase dates, simultaneous disposal dates and are under single managerial control; or form part of the initial setting up cost of a new building or refurbishment of a building irrespective of their individual or collective cost.

Where a large asset, e.g. a building, includes a number of components with significantly different asset lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives. Measurement Valuation of Property, Plant and Equipment All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at fair value. Fair values are determined as follows: • Land and non‐specialised buildings – market value for existing use • Specialised buildings – depreciated replacement cost Interest on borrowings is not capitalised within Fixed Assets in line with the ARM Subsequent expenditure Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the organisation and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de‐recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred. Depreciation Items of Property, Plant and Equipment are depreciated over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Freehold land is considered to have an infinite life and is not depreciated. Accelerated depreciation is applied when the useful life of a fixed asset has been reduced due to planned demolition. Property , Plant and Equipment which has been reclassified as "Held for Sale" ceases to be depreciated upon the reclassification.

217

Assets in the Course of Construction are not depreciated until the asset is brought into use. Revaluation gains, losses and impairment Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has been previously recognised in operating expenses, in which case they are recognised in operating income. Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of 'other comprehensive income'. The Foundation Trust commissioned a revaluation in 2013/2014 to ensure that its assets were correctly valued given changes in the property market and that of Land values. The revaluation was carried out using Modern Equivalent Asset valuation methodology which is used for specialised buildings and land. This works by valuing a hypothetical structure with the equivalent productive capacity, which could be built using modern materials, techniques, and design. Replacement cost is the basis used to estimate the cost of constructing a modern equivalent asset. The valuation was carried out as at 1st April 2013 by DTZ (now DTZ UGL) who are professionally qualified valuers in accordance with the Royal Institution of Chartered Surveyors (RICS) Appraisal and Valuation Manual. Where this method was deemed inappropriate the Valuer used Existing Use Valuation. An assessment is made annually of the value of assets, with a full revaluation conducted at least every 5 years. Impairments In accordance with the FT ARM, impairments that are due to a loss of economic benefits or service potential in the asset are charged to operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an amount equal to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment. An impairment arising from a loss of economic benefit or service potential is reversed when, and to the extent that, the circumstances that give rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment is recognised. Other impairments are treated as revaluation losses. Reversal of 'other impairments' are treated as revaluation gains. De‐recognition Assets intended for disposal are reclassified as 'Held for Sale' once all of the following criteria are met: • the asset is available for immediate sale in its present condition subject only to terms which are usual and

customary for such sales; • the sale must be highly probable i.e.: management are committed to a plan to sell the asset; an active

programme has begun to find a buyer and complete the sale; the asset is being actively marketed at a reasonable price; the sale is expected to be completed within 12 months of the date of classification as ' Held for Sale'; and the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it.

Following reclassification, the assets are measured at the lower of their existing carrying amount and their 'fair value less costs to sell'. Depreciation ceases to be charged. Assets are de‐recognised when all material sale contract conditions have been met.

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Plant, property and equipment which is to be scrapped or demolished does not qualify for recognition as 'Held for Sale' and instead is retained as an operational asset and the asset's economic life is adjusted. The asset is de‐recognised when scrapping or demolition occurs. Donated and other grant funded assets ‐ Revenue Government and other grants Donated and grant funded property, plant and equipment are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met. The donated and grant funded assets are subsequently accounted for in the same manner as the other items of property, plant and equipment. Inventories Inventories are valued at lower of cost and net realisable value. Computerised inventories are valued using the weighted average cost method. Intangible Assets The Trust does not have any intangible assets. Financial Instruments and Financial Liabilities Recognition Financial assets and financial liabilities which arise from contracts for the purchase or sale of non‐financial items (such as goods or services), which are entered into in accordance with the Trust’s normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs i.e. when receipt or delivery of the goods or services is made. Financial assets or financial liabilities in respect of assets acquired or disposed of through finance leases are recognised and measured in accordance with the accounting policy for leases described below. All other financial assets and liabilities are recognised when the Trust becomes a party to the contractual provisions of the instrument. De‐recognition All financial assets are de‐recognised when the rights to receive cash flows from the assets have expired or the Trust has transferred substantially all of the risks and rewards of ownership. Financial liabilities are de‐recognised when the obligation is discharged, cancelled or expires. Classification and Measurement Financial assets are categorised as loans and receivables. Financial liabilities are other financial liabilities. Loans and receivables Are non‐derivative financial assets with fixed or determinable payments which are not quoted in an active market. They are included in current assets. The Trust's receivables comprise: current investments, cash at bank and in hand, NHS debtors, accrued income and 'other debtors'. Loans and receivables are recognised initially at fair value, net of transactions costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset.

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Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive income. Other financial liabilities Are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability. They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as non‐current liabilities. Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to Finance Costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets. Determination of fair value For financial assets and financial liabilities carried at fair value, the carrying amounts are determined from their purchase or sale prices. Impairment of financial assets At the Statement of Financial Position date, the Trust assesses whether any financial assets are impaired. Financial assets are impaired and impairment losses are recognised if, and only if, there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cashflows of the asset. Cash and cash equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. Leases Finance leases Where substantially all the risks and rewards of ownership of a leased asset are borne by the Foundation Trust, the asset is recorded as Property, Plant and Equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease. The asset and liability are recognised at the inception of the lease. Thereafter the asset is accounted for as an item of property, plant and equipment. The annual rental is split between the repayment of the liability and a finance cost so as to achieve a constant rate of finance over the life of the lease. The annual finance cost is charged to Finance Costs in the Statement of Comprehensive Income. The lease liability, is de‐recognised when the liability is discharged, cancelled or expires. Operating leases Other leases are regarded as operating leases and the rentals are charged to the operating expenses on a straight‐line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease. Leases of land and buildings Where this is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately.

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Provisions The NHS Foundation Trust recognises a provision where it has a present legal or constructive obligation of uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other resources; and a reliable estimate can be made of the amount. The amount recognised in the Statement of Financial Position is the best estimate of the resources required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk‐adjusted cash flows are discounted using HM Treasury's discount rate of 2.2% in real terms, except for early retirement provisions and injury benefit provisions which both use the HM Treasury's pension discount rate of 1.8% in real terms. Clinical Negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS Foundation Trust pays an annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the NHS Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the NHS Foundation Trust is disclosed at note 15 but is not recognised in the NHS Foundation Trust's accounts. Non‐clinical Risk Pooling The NHS Foundation Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Trust pays an annual contribution to the NHS Litigation Authority and in return receives assistance with the costs of claims arising. The annual membership contributions, and any “excesses” payable in respect of particular claims are charged to operating expenses when the liability arises. Contingent Liabilities Contingent liabilities are not recognised, but are disclosed in note 16.3, unless the probability of a transfer of economic benefits is remote. Contingent liabilities are defined as: possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity's control; or present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability. Public Dividend Capital Public Dividend Capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of the establishment of the predecessor NHS trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32. A charge, reflecting the cost of capital utilised by the NHS Foundation Trust, is payable as Public Dividend Capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the Foundation Trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets, (ii) net cash balances held with the Government Banking Services and (iii) any PDC dividend balance receivable or payable. In accordance with the requirements laid down by the Department of Health (as the issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the 'pre‐audit' version of the annual accounts. The dividend thus calculated is not revised should any adjustment to net assets occur as a result of the audit of the annual accounts. Value added Tax Most of the activities of the NHS Foundation Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

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Corporation Tax Health service bodies, including Foundation Trusts, are exempt from tax on their principal health care income under section 519A ICTA 1988. In determining whether or not an activity is likely to be taxable, a three‐stage test may be employed: Is the activity an authorised activity related to the provision of core healthcare? The provision of goods and services for purposes relating to the provision of healthcare authorised under Section 14(1) of the HSCA is not treated as a commercial activity and is therefore tax exempt. It is expected that private healthcare is generally likely to fall within section 14(1) and is not therefore taxable. Is the activity actually or potentially in competition with the private sector? Activities of a commercial nature and activities in competition with the private sector may potentially be subject to corporation tax. It is expected that trading activities undertaken in house by many NHS organisations which are clearly ancillary to their core healthcare objectives and are not entrepreneurial in nature will not be subject to tax, e.g. staff canteens, or patient and hospital visitor car parking. A trading activity that is capable of being in competition with the wider private sector will be subject to tax. For example, the exploitation of intellectual property, or a commercial laundry are likely to be taxable since they represent the pursuit of business opportunities that extend beyond the physical or virtual confines of the hospital and its core healthcare activities. Are the annual profits significant? Only significant trading activity may be taxed. “Significant” for these purposes is defined as annual taxable profits in excess of £50,000 per trading activity. After considering the three stage test the Trust has concluded that it has no liability for Corporation Tax. Foreign Exchange Transactions that are denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. Resulting exchange gains and losses are taken to the Statement of Comprehensive Income. Third Party Assets Assets belonging to third parties refers to money held on behalf of patients and these assets are not recognised in the accounts since the NHS Foundation Trust has no beneficial interest in them. However, they are disclosed in a separate note to the accounts in accordance with the requirements of the HM Treasury Financial Reporting Manual. Losses and Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the NHS trust not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure). However the losses and special payments note is compiled directly from the losses and special payments register which reports on an accruals basis with the exception of provisions for future losses. Going Concern After making enquiries, the directors have a reasonable expectation that the NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. The Foundation Trust has submitted an

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annual plan to Monitor with forecasts for a further two years based on a going concern basis. The Foundation Trust cash position has been forecast for the following three years and maintains a going concern outlook. For this reason, they continue to adopt the going concern basis in preparing the accounts. Note 1.1 Segmental Analysis The Foundation Trust operates within a single reportable segment i.e. healthcare. This primarily covers the provision of a wide range of healthcare related services to the community of Gateshead and additionally, the provision of an increasing range of more specialised services to patients outside of the area. The Board of Directors/Chief Executive acts as the Chief Operating Decision Maker for the Foundation Trust and the monthly financial position of the Foundation Trust is presented/reported to them as a single segment. Group Foundation Trust

2013/14 2013/14 2013/14 2013/14 Total Healthcare Total Healthcare £000 £000 £000 £000

Income Income from activities 177,646 177,646 177,584 177,584Other operating income 25,780 25,780 25,106 25,106Total Operating Income 203,426 203,426 202,690 202,690Deficit by segment Operating deficit (13,342) (13,342) (13,551) (13,551)Operating deficit (13,342) (13,342) (13,551) (13,551)Net Assets: Total Assets 148,853 148,853 146,888 146,888Total Liabilities (46,460) (46,460) (46,444) (46,444)Segment net assets 102,393 102,393 100,444 100,444 Group Foundation Trust

2012/13 2012/13 2012/13 2012/13 Total Healthcare Total Healthcare £000 £000 £000 £000

Income Income from activities 171,724 171,724 171,724 171,724Other operating income 18,959 18,959 18,701 18,701Total Operating Income 190,683 190,683 190,425 190,425Surplus by segment Operating surplus 6,091 6,091 5,999 5,999Operating surplus 6,091 6,091 5,999 5,999 Net Assets: Total Assets 150,331 150,331 148,639 148,639Total Liabilities (30,319) (30,319) (30,296) (30,296)Segment net assets 120,012 120,012 118,343 118,343

The majority of the Trust's total income from activities is received/derived from CCGs and NHS England. Of the £177,584 reported in 2013/14 (2012/13: £171,724k), an amount of £175,720k i.e. 99% was attributable to CCGs / NHS England (2012/13: £167,867k i.e. 98%) This income from activities has arisen from Commissioner Requested Services.

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Note 2. Income

2.1 Operating Income from activities by classification Group Foundation


Trust 2013/14 2013/14 2012/13 2012/13£000 £000 £000 £000

Elective income 32,417 32,417 32,452 32,452Non elective income 44,684 44,684 42,665 42,665Outpatient income 23,405 23,405 32,344 32,344Other NHS Clinical income 70,194 70,194 55,838 55,838A & E income 5,794 5,794 6,826 6,826Private patient income 411 411 399 399Other clinical income 741 679 1,200 1,200Total Income from Activities 177,646 177,584 171,724 171,724Research and Development 611 611 477 477Education and training 5,846 5,846 5,787 5,787Charitable and other contributions to expenditure 0 0 126 126Non‐patient care services to other bodies 4,247 4,247 3,740 3,740Other income 5,580 5,580 6,900 6,900Profit on disposal of other tangible fixed assets 0 0 0 0Profit on disposal of land and buildings 290 290 264 264Reversal of impairments of property, plant and equipment 184 184 291 291Rental revenue from finance leases 0 0 48 48Rental revenue from operating leases 390 390 437 437Rental revenue from operating leases ‐ contingent rents 45 45 0 0Income in respect of staff costs 8,097 8,097 631 631NHS Charitable Funds Incoming resources excluding investment income 490 0 258 0

25,596 25,106 18,959 18,701Total Operating Income 203,242 202,690 190,683 190,425

All services are Mandatory except Private patients. Group 2.1.1 Private patient income Base year

2013/14 2002/03 2012/13 £000 £000 £000

Private patient income 411 194 399 Total patient related income 177,646 64,667 171,724 Proportion (as percentage) 0.23% 0.30% 0.23% Foundation Trust

2013/14 2002/03 2012/13 £000 £000 £000

Private patient income 411 194 399 Total patient related income 177,584 64,667 171,724 Proportion (as percentage) 0.23% 0.30% 0.23%

Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) requires that the income from the provision of goods and services for the purposes of the health service in England must be greater than its income from the provision of goods and services for any other purposes. The Foundation Trust has met this requirement.

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2.2 Operating lease income Group & Foundation

Trust 2013/14 2012/13 £000 £000

Operating lease income Rents recognised as income in the period 436 437

Total 436 437Future minimum lease payments due ‐ not later than one year 412 407 ‐ later than one year and not later than five years 1,195 1,323 ‐ later than five years 0 0Total 1,607 1,730

2.3 Income from activities by source Group Foundation


Trust 2013/14 2013/14 2012/13 2012/13 £000 £000 £000 £000

NHS Foundation Trusts 318 318 81 81NHS Trusts 1 1 0 0Strategic Health Authorities 0 0 2,258 2,258CCGs and NHS England 173,070 173,070 0 0Primary Care Trusts 0 0 167,867 167,867Local Authorities 422 422 1 1Department of Health ‐ grants 0 0 0 0Department of Health ‐ other 0 0 0 0NHS Other 2,682 2,682 82 82Non‐NHS Private patients 411 411 399 399Non‐NHS Overseas patients (non‐reciprocal) 0 0 0 0NHS injury scheme 664 664 982 982Non NHS other 78 16 54 54Total Income from Activities 177,646 177,584 171,724 171,724

Injury cost recovery income is subject to a provision for impairment of receivables of 7.8% to reflect expected rates of collection.

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2.4 Other Operating Income Group Foundation


Trust 2013/14 2013/14 2012/13 2012/13 £000 £000 £000 £000

Research and development 611 611 477 477Education and Training 5,846 5,846 5,787 5,787Charitable and other contributions to expenditure 0 0 126 126Non‐patient care services to other bodies 4,247 4,247 3,740 3,740Profit on disposal of land and buildings 290 290 264 264Profit on disposal of other tangible fixed assets 0 0 0 0Reversal of impairments of property,plant and equipment 184 184 291 291Rental revenue from finance leases 0 0 48 48Rental revenue from operating leases minimum lease payments 390 390 437 437Rental revenue from operating leases contingent rent 46 46 0 0Car Parking 868 868 707 707Estates Recharges 0 0 76 76IT recharges 4 4 0 0Pharmacy Sales 34 34 133 133Staff costs 8,097 8,097 631 631Creche Services 272 272 305 305Clinical Test Services 571 571 547 547Clinical Excellence Awards 146 146 0 0Charitable Funds NHS income excluding investment income 490 0 258 0Catering 809 809 808 808Property Rentals 0 0 47 47Other 2,875 2,875 4,277 4,277Total Other Operating income 25,596 25,106 18,959 18,701

2.4.1 Other Operating Income – Other Group

& Foundation

Trust

Group &

Foundation Trust

2013/14 2012/13 £000 £000

Telecommunications 18 9CSSD 8 220Trials 4 84Sponsorship 105 115TSS 187 119Salary sacrifice 76 420Training 71 42Capital schemes funding 0 400Other 2,407 2,869Total Other Operating Income ‐ other 2,876 4,278

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Note 3. Expenses

3.1 Operating expenses comprise Group Foundation


Trust 2013/14 2013/14 2012/13 2012/13£000 £000 £000 £000

Services from NHS Foundation Trusts 3,788 3,788 2,676 2,676Services from NHS Trusts 10 10 5 5Services from PCTs 0 0 534 534Services from CCGs and NHS England 0 0 0 0Services from other NHS Bodies 0 0 899 899Purchase of healthcare from non NHS Bodies 1,757 1,757 342 342Employee Expenses ‐ Executive directors 932 932 918 918Employee Expenses ‐ Non‐executive directors 159 159 154 154Employee Expenses ‐ Staff 132,034 132,034 120,269 120,269NHS Charitable Funds ‐employee expenses 0 0 0 0Drug Costs (non inventory) 26 26 84 84Supplies and services ‐ clinical (excluding drugs costs) 19,226 19,226 17,916 17,916Supplies and services ‐ general 2,935 2,935 2,882 2,882Establishment 2,800 2,800 3,057 3,057Research and development (Not included in employee expenses) 5 5 5 5 Research and development (included in employee expenses) 239 239 195 195 Change in Provisions discount rates 135 135 0 0Transport (Business travel only) 723 723 312 312Transport (Other) 188 188 0 0Premises 8,695 8,695 9,448 9,448Increase/(decrease) in bad debt provision 85 85 (6) (6) Increase in other provisions 383 383 0 0Inventories written down (net, including inventory drugs) 0 0 0 0Drugs Inventories consumed 14,031 14,031 12,387 12,387Rentals under Operating Leases (minimum lease payments) 2,098 2,098 2,314 2,314Rentals under Operating Leases (contingent rent payments) 0 0 0 0Rentals under Operating Leases (sub lease receipts) (1,052) (1,052) (1,171) (1,171) Depreciation on property, plant and equipment 4,287 4,287 5,455 5,455Impairments of Property, Plant & Equipment 16,150 16,150 1,087 1,087Audit fees audit services ‐statutory audit 49 42 39 36audit services ‐regulatory reporting 9 9 9 9

Other auditors' remuneration Other services 0 0 0 0

Clinical negligence 3,010 3,010 2,790 2,790Loss on Disposal of Land and Buildings 0 0 51 51Loss on Disposal of other Property , Plant & Equipment 0 0 0 0Legal Fees 96 96 107 107Consultancy Costs 559 559 387 387Training courses and conferences 648 648 622 622Patients' Travel 18 18 17 17Car parking & Security 632 632 0 0Voluntary Severance Payments 686 686 0 0Redundancy 387 387 0 0Hospitality 10 10 7 7Insurance 119 119 86 86Other Services 184 184 180 180NHS Charitable funds other resources expended 336 0 163 0Losses, ex‐gratia and special payments 163 163 384 384Other 228 228 (12) (12)

216,768 216,425 184,592 184,426

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Group & Foundation

Trust

Group & Foundation

Trust 3.2 Operating leases Payments recognised as an expense 2013/14 2012/13

£000 £000 Minimum lease payments 2,098 2,314Sub‐lease payments * (1,052) (1,171)

1,046 1,143Total future minimum lease payments 2013/14 2012/13

£000 £000 Payable: Not later than one year 1,571 1,727Between one and five years 1,342 1,816After 5 years 56 11Total 2,969 3,554* Sub‐lease payments relate to contributions from employees in the Trust's Green Car Salary Sacrifice scheme 3.3 The Late Payment of Commercial Debts (Interest) Act 1998 No claims were made against the Group or the Foundation Trust during the accounting period under this legislation. No compensation was paid to cover debt recovery under this legislation. 3.4 Better Payment Policy ‐ Foundation Trust 2013/14 2012/13

Number £000 Number £000 Total bills paid in the year 49,945 109,681 51,875 87,850 Total bills paid within target 46,663 104,282 49,944 85,572 Percentage of bills paid within target 93.4% 95.1% 96.3% 97.4%

The Better Payment Practice Code requires the Foundation Trust to aim to pay all valid invoices by the due date or within 30 days of receipt of goods or a valid invoice, with the exception of small to medium sized businesses which, under the recommendation of central government, are paid within 10 days of receipt of goods and services wherever possible. Note 4. Employee expenses, numbers and benefits 4.1 Employee expenses (Including Executive Directors' Costs) Group & Foundation Trust

2013/14 Total

Permanently Employed

Other 2012/13 Total

£000 £000 £000 £000 Salaries and wages 111,241 107,540 3,701 101,480Capitalised Salaries and wages (54) (54) 0 (106) Social Security Costs 8,163 7,949 214 7,545Pension costs ‐ defined contribution plans 12,445 12,117 328 11,047Employers' contributions to NHS Pensions Other pension costs 0 0 0 0Agency/contract staff 1,409 n/a 1,409 1,416NHS Charitable Funds staff 0 0 0 0Termination Benefits 1,073 1,073 0 0Total Gross Staff Costs 134,277 128,625 5,652 121,382

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4.2 Number of persons employed at 31st March 2014 (The figures shown represent the Whole Time Equivalent as opposed to the number of employees) Group & Foundation Trust

2013/14 Total

Permanently Employed Other

2012/13 Total

Number Number Number Number Medical and dental 333 329 4 327Ambulance staff 0 0 0 0Administration and estates 729 729 0 700Healthcare assistants and other support staff 672 672 0 636Nursing, midwifery and health visiting staff 850 850 0 851Scientific, therapeutic and technical staff 584 584 0 478Bank and agency staff 80 0 80 84Other * 27 27 0 30Total 3,275 3,191 84 3,106* Other relates to Apprentices employed by the Trust 4.3 Retirements due to ill‐health During 2013/14 there were six early retirements from the Trust on the grounds of ill‐health at an additional cost to the pension scheme of £340,332. (In 2012/13 there were 2. The cost of these liabilities were estimated at £29,114). These costs were borne by the NHS Pensions Agency. 4.4 Staff Exit Packages 2013/14 Group & Foundation Trust

Exit package cost band

Number of compulsory departures agreed

Cost of compulsory departures agreed £000s

Number of non

compulsory departures agreed

Cost of non compulsory departures agreed £000s

< £10,000 0 0 6 38£10,001 ‐ £25,000 6 108 26 428£25,001 ‐ £50,000 1 28 5 182£50,001 ‐ £100,000 0 0 0 0£100,001 ‐ £150,000 1 126 0 0£150,001 ‐ £200,000 1 163 0 0> £200,001 0 0 0 0

9 425 37 648Redundancy 9 425 0 0Voluntary Severance Scheme 0 0 37 648Total 9 425 37 648

The table above shows the number and cost of exit packages agreed by the Trust in 2013/14. The non compulsory departures are in respect of the voluntary severance scheme. The compulsory departures relate to redundancy payments made in the year, of which seven are due to the closure of the Trust’s Day Nursery facility. There were no exit packages agreed by the Trust in 2012/13.

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4.5 Salary and pension entitlements of senior managers A) Remuneration

2012/13 Name and Title 2013/14

Salary Other Remuneration

Benefits in Kind

Pension‐related Benefits Total Salary Other

Remuneration Benefits in

Kind Pension‐related

Benefits Total

(bands of £5000) £000

(bands of £5000) £000


£100

(bands of £2500) £000

(bands of £5000) £000

(bands of £5000) £000

(bands of £5000) £000


£100

(bands of £2500) £000

(bands of £5000) £000

10 ‐15 0 300 0 10 ‐15 Mr PJ Smith Chairman (to 30 Jun 2012) N/A N/A N/A N/A N/A 30 ‐35 0 0 0 30 ‐35 Mrs JEA Hickey Chairman (from 1 Jul 2012) 45 ‐50 0 0 0 45 ‐50

205 ‐210 0 12,700 107.5 ‐110.0 330 ‐335 Mr ID Renwick Chief Executive 210 ‐215 0 8,000 32.5 ‐35.0 255 ‐260

130 ‐135 0 8,800 42.5 ‐45.0 180 ‐185 Mrs YA Ormston Director of Transformation & Compliance and Deputy Chief Executive 130 ‐135 0 9,700 27.5 ‐30.0 170 ‐175

120 ‐125 0 4,400 97.5 ‐100.0 220 ‐225 Mrs G MacArthur Director of Nursing, Midwifery & Quality 120 ‐125 0 5,500 35.0 ‐37.5 160 ‐165

55 ‐60 135 ‐140 * 0 (30.0) ‐(27.5) 160 ‐165 Dr DM Beaumont Medical Director (to 31 Jan N/A N/A N/A N/A N/A

10 ‐15 0 0 0 10 ‐15 Mrs T Preece Acting Director of Finance & Information (to 29 Apr 2012) N/A N/A N/A N/A N/A

115 ‐120 0 600 237.5 ‐240.0 355 ‐360 Mr JM Connolly Director of Finance & Information (from 30 Apr 2012) 130 ‐135 0 8,100 37.5 ‐40.0 180 ‐185

135 ‐140 0 1,800 37.5 ‐40.0 175 ‐180 Mr P Harding Director of Estates & Facilities 135 ‐140 0 7,800 (52.5) ‐(50.0) 90 ‐95

N/A N/A N/A N/A N/A Mr S Bowron Non Executive Director (from 1 Jul 2013) 10 ‐15 0 0 0 10 ‐15

10 ‐15 0 0 0 10 ‐15 Mr MJ Brown Non Executive Director 10 ‐15 0 0 0 10 ‐15 10 ‐15 0 0 0 10 ‐15 Dr JM Bryson Non Executive Director 10 ‐15 0 0 0 10 ‐15 10 ‐15 0 0 0 10 ‐15 Dr AF Fairbairn Non Executive Director 10 ‐15 0 0 0 10 ‐15

10 ‐15 0 0 0 10 ‐15 Mr MW Graham Non Executive Director (to 30 Jun 2013) 0 ‐5 0 0 0 0 ‐5

N/A N/A N/A N/A N/A Mr MF Henry Non Executive Director (from 1 Jul 2013) 10 ‐15 0 0 0 10 ‐15

0 ‐5 0 0 0 0 ‐5 Mrs JEA Hickey Non Executive Director (to 30 Jun 2012) N/A N/A N/A N/A N/A

5 ‐10 0 0 0 5 ‐10 Ms KA Larkin‐Bramley Non Executive Director (from 1 Oct 2012) 15 ‐20 0 0 0 15 ‐20

15 ‐20 0 0 0 15 ‐20 Mr FG Major Non Executive Director 15 ‐20 0 0 0 15 ‐20

10 ‐15 0 0 0 10 ‐15 Mr RE Simpson Non Executive Director (to 30 Jun 2013) 0 ‐5 0 0 0 0 ‐5

45 ‐50 0 0 0 45 ‐50 Mrs D Atkinson Trust Secretary 45 ‐50 0 0 0 45 ‐50

25 ‐30 125 ‐130 * 0 (65.0) ‐(62.5) 85 ‐90 Mr K Godfrey Medical Director (Full Medical Director from 1 Feb 2013) 65 ‐70 115 ‐120 * 0 (1,607.5) ‐

(1,605.0) (1,425) ‐(1,420)

NB all senior managers are continuing except where stated. * Other remuneration refers to that as a consultant. Benefits in Kind relate to lease car payments made by the Trust. No other remuneration or pensions contributions are paid to/for these senior managers. There were no golden hellos or compensation for loss of office.

230

4.5 Salary and pension entitlements of senior managers A) Remuneration (continued) 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.

2012/13 2013/14

205 ‐ 210 Band of Highest Paid Director's Total Remuneration ‐ £000 220 ‐ 225

25,579 Median Total Remuneration ‐ £ 25,831

8.1 Ratio 8.6 The banded remuneration of the highest‐paid director in Gateshead Health NHS Foundation Trust in the financial year 2013/14 was £220k ‐ £225k. This was 8.6 times the median remuneration of the workforce, which was £25,831. In 2013/14, 0 employees received remuneration in excess of the highest paid director. Total remuneration ranged from £0k ‐ £5k to £220k ‐ £225k (bands of £5,000). Total remuneration includes salary, benefits‐in‐kind, non‐consolidated performance‐related pay as well as severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions.

231

4.5 Salary and Pension entitlements of senior managers B) Pension Benefits

Name and title

Real increase in

pe

nsion at age 60

Total accrued

pe

nsion at age 60 at

31 M

arch 2014

Real increase in

lump sum at a

ge 60

Total accrued

lump

sum at a

ge 60 at 31

March 201

4

Cash Equ

ivalen

t Tran

sfer Value

at 3

1 March 201

4

Cash Equ

ivalen

t Tran

sfer Value

at 3

1 March 201

3

Real In

crease in

Ca

sh Equ

ivalen

t Tran

sfer Value

Employers

Contrib

ution to

Stakeh

olde

r Pen

sion

(bands of £2500) £000

(bands of £5000) £000

(bands of £2500) £000

(bands of £5000) £000

£000 £000 £000 To

nearest £100

Mr ID Renwick Chief Executive 0.0 ‐ 2.5 65.0 ‐ 70.0 2.5 ‐ 5.0 200.0 ‐ 205.0 1,195 1,116 55 0 Mr JM Connolly Director of Finance & Information 0.0 ‐ 2.5 30.0 ‐ 35.0 5.0 ‐ 7.5 100.0 ‐ 105.0 558 491 42 0 Mrs YA Ormston Director of Transformation & Compliance and Deputy Chief Executive 0.0 ‐ 2.5 40.0 ‐ 45.0 2.5 ‐ 5.0 130.0 ‐ 135.0 822 760 46 0 Mrs G MacArthur Director of Nursing, Midwifery and Quality 0.0 ‐ 2.5 40.0 ‐ 45.0 2.5 ‐ 5.0 125.0 ‐ 130.0 1,065 783 265 0 Mr P Harding Director of Estates & Facilities (2.5) ‐ 0.0 45.0 ‐ 50.0 (7.5) ‐ (5.0) 140.0 ‐ 145.0 933 930 (17) 0 Mrs D Atkinson Trust Secretary 0.0 ‐ 2.5 15.0 ‐ 20.0 0.0 ‐ 2.5 50.0 ‐ 55.0 337 308 13 0 Mr K Godfrey Medical Director (70.0) ‐ (67.5) 0 (210.0) ‐ (207.5) 0 0 0 0 0

A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member's accrued benefits and any contingent spouse's pension payable from the scheme. A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which the disclosure applies. The CETV figures, and the other pension details, include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real Increase in CETV ‐ This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement) and uses common market valuation factors for the start and end of the period.

232

5. Finance Income Group Foundation


Trust 2013/14 2013/14 2012/13 2012/13 £000 £000 £000 £000

Interest received on commercial bank accounts 77 77 243 243NHS Charitable Funds Investment Income 48 0 48 0

125 77 291 243

Group & Foundation

Trust

Group & Foundation

Trust 6.1 Finance costs ‐ interest expense 2013/14 2012/13

£000 £000 Finance Leases 41 57Foundation Trust Financing Facility Loan 621 146

662 203

Group & Foundation

Trust

Group & Foundation

Trust 6.2 Impairment of Assets 2013/14 2012/13

£000 £000 Unforeseen Obsolescence 24,781 1,364Reversal of impairments (184) (291) Total Impairments 24,597 1,073

2013/14 2012/13 £000 £000

Charge to Income Statement 15,966 796Charge to Other Comprehensive Income 8,631 277Revaluation Reserve at 31 March 2014 24,597 1,073

7. Intangible Fixed Assets The Foundation Trust had no recorded intangible assets at the Statement of Financial Position date nor in the prior period.

233

Note 8. Property, plant and equipment ‐Group and Foundation Trust 8.1 Property, plant and equipment 2013/14 Total Land

Buildings excluding dwellings

Assets under construction

and payments on

account

Plant and Machinery

Transport Equipment


Furniture & fittings

2013/14 £000 £000 £000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 2013 148,454 4,100 108,628 10,363 14,221 94 10,987 61 Additions purchased 28,238 0 2,267 21,882 1,338 17 2,708 26 Additions donated 47 0 0 0 47 0 0 0 Impairments (13,361) (79) (13,282) 0 0 0 0 0 Reversal of impairments 0 0 0 0 0 0 0 0 Reclassifications 0 0 (262) 262 0 0 0 0 Revaluations 0 0 0 0 0 0 0 0 Transferred to disposal group as asset held for sale 0 0 0 0 0 0 0 0 Disposals (2,302) 0 (79) 0 (2,146) 0 (77) 0 Cost or valuation at 31 March 2014 161,076 4,021 97,272 32,507 13,460 111 13,618 87 Accumulated Depreciation at 1 April 2013 32,425 0 14,677 0 10,213 46 7,470 20 Provided during the year 4,287 0 1,287 0 1,558 9 1,423 10 Impairments 16,334 986 15,343 0 5 0 0 0 Reversal of impairments (368) 0 (368) 0 0 0 0 0 Revaluations (2,365) 0 (2,365) 0 0 0 0 0 Revaluation surpluses (2,365) 0 (2,365) 0 0 0 0 0 Transferred to disposal group as asset held for sale 0 0 0 0 0 0 0 0 Disposals (2,216) 0 0 0 (2,140) 0 (76) 0 Accumulated Depreciation at 31 March 2014 45,732 986 26,209 0 9,636 55 8,817 30 Net book value ‐ 31 March 2013 ‐ Owned 115,360 4,100 93,923 10,363 3,375 49 3,509 41 ‐ Finance lease 199 0 0 0 199 0 0 0 ‐ Donated 470 0 28 0 434 0 8 0 Total NBV at 31 March 2013 116,029 4,100 93,951 10,363 4,008 49 3,517 41 Net book value ‐ 31 March 2014 ‐ Owned 114,888 3,035 71,036 32,507 3,401 56 4,795 57 ‐ Finance lease 121 0 0 0 121 0 0 0 ‐ Donated 336 0 28 0 302 0 6 0 Total NBV at 31 March 2014 115,344 3,035 71,064 32,507 3,824 56 4,801 57

234

8.2 Analysis of tangible fixed assets

Total Land Buildings excluding dwellings

Assets under

construction and

payments on account

Plant & Machinery

Transport Equipment



£000 £000 £000 £000 £000 £000 £000 £000 Net book value ‐ Protected assets at 31 March 2014 73,552 3,035 70,517 0 0 0 0 0 ‐ Unprotected assets at 31 March 2014 41,791 0 575 32,503 3,799 56 4,801 57 Total at 31 March 2013 115,344 3,035 71,092 32,503 3,799 56 4,801 57

Property is deemed “protected” if it is required for the purposes of providing either the mandatory goods and services or the mandatory education and training as defined Impairment classification explained in note 8.7 The Group and the Trust's land and buildings were revalued at the 1st April 2013 by external valuers. Further information is included in note 1, accounting policies. As a result of this revaluation a net £15,661,000 was charged to the income statement (being impairments of £15,845,000 less impairment reversals of £184,000) and £8,246,000 was debited to the revaluation reserve. There were other impairments of £690,000 of which £305,000 was charged to the income statement and £385,000 charged to the revaluation reserve. Assets under construction were not included in this revaluation.

235

8.3 Property, plant and equipment 2012/13 ‐ Group and Foundation Trust

2012/13


Assets under

construction and

payments on account

Plant and Machinery

Transport Equipment



£000 £000 £000 £000 £000 £000 £000 £000 Cost or valuation at 1 April 2012 135,839 4,100 100,206 3,156 18,002 86 9,906 383 Additions purchased 16,696 0 3,630 10,642 904 9 1,511 0 Additions donated 126 0 0 0 118 0 8 0 Impairments charged to revaluation reserve (277) 0 (275) (2) 0 0 0 0 Reclassifications 0 0 6,394 (3,433) (3,042) 0 31 49 Revaluation surpluses 19 0 0 0 19 0 0 0 Disposals (4,331) 0 (1,328) 0 (2,164) 0 (469) (371) Cost or valuation at 31 March 2013 148,071 4,100 108,628 10,363 13,838 94 10,987 61 Accumulated Depreciation at 1 April 2012 30,069 0 9,514 0 13,502 33 6,644 376 Provided during the year 5,455 0 2,606 0 1,558 13 1,273 6 Impairments 1,087 0 1,004 0 79 0 0 4 Reversal of Impairments (291) 0 (291) 0 0 0 0 0 Reclassifications (0) 0 3,120 0 (3,148) 0 22 6 Revaluation surpluses 0 0 0 0 0 0 0 0 Disposals (4,278) 0 (1,277) 0 (2,161) 0 (469) (371) Accumulated Depreciation at 31 March 2013 32,042 0 14,677 0 9,830 46 7,470 20 Net book value at 1st April 2012 ‐ Owned at 1 April 2012 103,763 4,100 90,664 3,156 2,521 53 3,262 7 ‐ Finance lease at 1 April 2012 1,547 0 0 0 1,547 0 0 0 ‐ Donated at 1 April 2012 460 0 28 0 432 0 0 0 Total NBV at 1 April 2012 105,770 4,100 90,692 3,156 4,500 53 3,262 7 Net book value at 31st March 2013 ‐ Owned 115,360 4,100 93,923 10,363 3,375 49 3,509 41 ‐ Finance lease 199 0 0 0 199 0 0 0 ‐ Donated 470 0 28 0 434 0 8 0 Total NBV at 31 March 2013 116,029 4,100 93,951 10,363 4,008 49 3,517 41

236

8.4 Prior Year ‐ Analysis of tangible fixed assets


Assets under

construction and

payments on account

Plant & Machinery

Transport Equipment



£000 £000 £000 £000 £000 £000 £000 £000 Net book value ‐ Protected assets at 31 March 2013 97,790 4,100 93,690 0 0 0 0 0 ‐ Unprotected assets at 31 March 2013 18,239 0 261 10,363 4,008 49 3,517 41 Total at 31 March 2013 116,029 4,100 93,951 10,363 4,008 49 3,517 41

237

8.5 Economic life of Property, Plant and Equipment Group & Foundation Trust Min Life Max Life

Years Years Land 0 0Buildings excluding dwellings 15 85Dwellings 0 0Plant & Machinery 4 15Transport Equipment 5 7Information Technology 5 5Furniture & Fittings 5 5

8.6. Profit / (Loss) on Disposal of Fixed Assets Group & Foundation Trust Profit / (Loss) on the disposal of fixed assets is made up as follows:

2013/14 2012/13 £000 £000

Profit / (Loss) on disposal of Property Plant & Equipment 290 (53)290 (53)

8.7 Revaluation Reserve ‐ property, plant and equipment Group & Foundation Trust

Total £000

Revaluation reserve at 1 April 2013 16,830Revaluations (8,631) Asset disposals (88) Revaluation Reserve at 31 March 2014 8,111Revaluation reserve at 1 April 2012 17,352Impairments (277) Revaluations 19Asset disposals (264) Revaluation reserve at 1 April 2013 16,830

8.8 Investments ‐ Group

Group Group 2013/14 2012/13 £000 £000

Charitable Fund Investments 1,481 1,3631,481 1,363

The Foundation Trust did not make any Investments in the financial year.

238

Note 9. Finance leases Note 9.1 Finance lease receivables ‐ Group & Foundation Trust

31 March 31 March 2014 2013 £000 £000

Gross lease receivables 1,728 1,834of which those receivable ‐ not later than one year 104 106 ‐ later than one year and not later than five years 394 403 ‐ later than five years 1,230 1,325Unearned interest income (480) (526) Net lease receivables 1,248 1,308of which those receivable ‐ not later than one year 60 60 ‐ later than one year and not later than five years 240 240 ‐ later than five years 948 1,008

1,248 1,308 Note 9.2 Finance lease details ‐ Group & Foundation Trust

31 March 31 March 2014 2013 £000 £000

The unguaranteed residual value accruing to the FT 1,500 1,500The accumulated allowance for uncollectable minimum lease payments receivable 1,188 1,248Contingent rents recognised as income in the period 60 60

239

Note 10. Receivables 10.1 Trade and Other Receivables

31st March 2014

Financial assets

Non‐ financial assets

31st March 2013

Financial assets

Non‐ financial assets

£000 £000 £000 £000 £000 £000 Current ‐ Group NHS Receivables * 8,623 8,623 0 3,002 3,002 0Other receivables with related parties 156 0 156 256 0 256Provision for impaired receivables (213) (66) (147) (203) (126) (77)Prepayments 1,658 0 1,658 1,086 0 1,086Accrued Income 62 62 0 38 38 0Other receivables 2,450 1,518 932 2,947 1,962 985

Total Current Trade and Other Receivables 12,736 10,137 2,599 7,126 4,876 2,250Current ‐ Trust NHS Receivables * 8,623 8,623 0 3,002 3,002 0Other receivables with related parties 152 0 152 250 0 250Provision for impaired receivables (213) (66) (147) (203) (126) (77)Prepayments 1,658 0 1,658 1,086 0 1,086Accrued Income 62 62 0 38 38 0Other receivables 2,421 1,489 932 2,947 1,962 985

Total Current Trade and Other Receivables 12,703 10,108 2,595 7,120 4,876 2,244Non‐Current Group & Trust NHS Receivables * 1,188 1,188 0 1,247 1,247 0Provision for impaired receivables (147) 0 (147) (77) 0 (77)Other receivables** 931 0 931 985 0 985

Total Non Current Trade and Other Receivables 1,972 1,188 784 2,155 1,247 908 * The majority of NHS receivables are with Clinical Commissioning Groups and NHS England, as commissioners for NHS patient care services. NHS receivables that are neither past due date nor impaired are expected to be paid within their agreed terms. ** Relates to outstanding insurance claims made under a third party with the Compensation Recovery Unit. Note 10.2 Provision for impairment of receivables Group & Foundation Trust

2013/14 2012/13 £000 £000

At 1 April 280 309Increase in provision 169 89Amounts utilised (4) (23) Unused amounts reversed (85) (95)

At 31 March 360 280

240

Note 10.3 Analysis of impaired receivables past their due date Group & Foundation Trust

31 March 31 March 2014 2013 £000 £000

0 ‐ 30 days 17 1230‐60 days 10 860‐90 days 18 890‐ 180 days 52 35> 180 days 263 217Total 360 280

Note 10.4 Analysis of non‐impaired receivables past their due date Group & Foundation Trust

31 March 31 March 2014 2013 £000 £000

0 ‐ 30 days 3,003 83030‐60 days 497 35460‐90 days 254 20690‐ 180 days 316 333> 180 days 1,237 1,290Total 5,307 3,013

Note 11. Inventory ‐ Group & Foundation Trust Note 11.1 Inventory Balances

31 March 2014

31 March 2013

£000 £000 Drugs 992 823Consumables 1,261 1,220Energy 63 77Total Inventories 2,316 2,120

Note 11.2 Inventories Recognised as an Expense Group & Foundation Trust 31 March

2014 31 March 2013

£000 £000 Inventories recognised in expenses 20,523 12,387

20,523 12,387

241

Note 12. Cash and cash equivalents Foundation Trust Group

31 March 2014

31 March 2013

31 March 2014

31 March 2013

£000 £000 £000 £000 At 1 April 21,215 20,823 21,538 20,963

Net change in year (6,662) 392 (6,534) 575At 31 March 14,553 21,215 15,004 21,538

Broken down into: Cash at commercial banks and in hand 190 108 641 431Cash with Government Banking Service 14,363 21,107 14,363 21,107

Cash and cash equivalents as in Statement of Financial Position 14,553 21,215 15,004 21,538

Bank overdraft 0 0 0 0Cash and cash equivalents as in Statement of Cashflows 14,553 21,215 15,004 21,538

242

Note 13. Payables and other Liabilities 13.1 Trade and other payables

Group

Total 31st March

2014 Financial liabilities

Non‐financial liabilities

Total 31st March 2013

Financial liabilities


Current £000 £000 £000 £000 £000 £000 NHS payables 2,485 2,485 0 1,855 1,855 0 Other trade payables 0 0 0 40 40 0 Trade Payables‐Capital 2,509 2,509 0 3,593 3,593 0 Other payables 7,835 7,835 0 8,503 8,503 0 Accruals 4,805 4,805 0 3,926 3,926 0 Total current trade and other payables 17,634 17,634 0 17,917 17,917 0 Non‐current Other payables * 462 462 0 721 721 0 Total non‐current trade and other payables 462 462 0 721 721 0

Trust

Total 31st March



Total 31st March



Current £000 £000 £000 £000 £000 £000 NHS payables 2,485 2,485 0 1,855 1,855 0 Other trade payables 0 0 0 40 40 0 Trade Payables‐Capital 2,509 2,509 0 3,593 3,593 0 Other payables 7,819 7,819 0 8,479 8,479 0 Accruals 4,805 4,805 0 3,926 3,926 0 Total current trade and other payables 17,618 17,618 0 17,893 17,893 0 Non‐current Other payables * 462 462 0 721 721 0 Total non‐current trade and other payables 462 462 0 721 721 0

*Creditor with Her Majesty's Revenue & Customs relating to VAT claims submitted under the "Lennartz" ruling. Repayment of recoverable input tax VAT over a ten year period following legislation by the European Court of Justice.

243

13.2 Other Liabilities ‐ Group & Foundation Trust 31st March

2014 31st March

2013 Current Deferred Income 2,855 3,738Total other current liabilities 2,855 3,738

Non‐current Deferred Income 0 0Total other non current liabilities 0 0

Note 14. Borrowings ‐ Group & Foundation Trust 14.1 Borrowings

31 March 2014

31 March 2013

£000 £000 Current Loans from Foundation Trust Financing Facility 999 0Obligations under finance leases 49 103Total current borrowing 1,048 103

Non‐current Loans from Foundation Trust Financing Facility 21,001 4,600Obligations under finance leases 72 96Total other non current liabilities 21,073 4,696

The Trust has drawn down £22.0m against its long term borrowing agreement with the Foundation Trust Financing Facility (FTFF). The Trust did not use any of the £12m agreed working capital facility with Lloyds Bank PLC. The FTFF facility is repayable over 25 years commencing 2014/15 at an interest rate of 3.78% 14.2 Prudential Borrowing Limit The prudential borrowing code requirements in section 41 of the NHS Act 2006 have been repealed with effect from 1 April 2013 by the Health and Social Care Act 2012. The financial statements disclosures that were provided previously are no longer required. 14.3 Finance Lease Obligations ‐ Group & Foundation Trust

31 March 31 March 2014 2013 £000 £000

Gross Lease Liabilities 121 199Of which liabilities are due:‐ ‐ Not later than one year 49 103‐ Later than one year and not later than five years 72 96Net Lease Liabilities 121 199‐ Not later than one year 49 103‐ Later than one year and not later than five years 72 96

121 199

244

Note 15. Provisions for liabilities and charges Group & Foundation Trust Current Non Current

31 March 31 March 31 March 31 March 2014 2013 2014 2013 £000 £000 £000 £000

Pensions relating to former directors 11 11 132 129Pensions relating to other staff 164 155 1,401 940Legal claims 147 118 0 0Equal Pay 0 370 0 0Other 102 164 1,431 1,258

424 818 2,964 2,327

Pensions relating to former directors

Pensions relating to other staff

Legal Claims Equal Pay Other Total

£000 £000 £000 £000 £000 £000 At 1 April 2013 140 1,095 118 370 1,422 3,145Change in the discount rate 6 54 0 0 75 135Arising during the year 4 549 92 0 181 826Utilised during the year (10) (153) (42) (25) (94) (324) Reversed unused 0 0 (23) (345) (75) (443) Unwinding of discount 3 20 2 0 24 49At 31 March 2014 143 1,565 147 0 1,533 3,388Expected timing of cash flows: ‐not later than one year; 11 164 147 0 102 424‐later than one year and not later than five years; 49 700 0 0 402 1,151 ‐later than five years; 83 701 0 0 1,029 1,813

143 1,565 147 0 1,533 3,388 £20,701,527 is included in the provisions of the NHS Litigation Authority at 31/3/2014 in respect of clinical negligence liabilities of the trust which are managed through the NHS risk pooling scheme on behalf of the Foundation Trust (31/3/2013 £18,832,961). i) Pensions relating to directors and other staff represents the present value of quarterly payments to the

NHS Pensions Agency in respect of the unfunded element of the pensions of staff and directors who have taken early retirement. The provisions are uncertain to the extent that the period over which payments will be made is an estimate.

ii) Other Legal claims £147k relates to a provision for Employer Liability claim which are covered under the terms of the Trust's commercial insurance. Provisions are stated net of reimbursements from the Trust's insurers. The Trust is liable for excess payments against each claim under the terms of the commercial insurance.

iii) Other Provisions £1,533k relate to Service Injury Benefit payments reimbursed to the NHS Pensions Agency in respect of former staff with service related injuries. The provision represents the present value of quarterly payments to the NHS Pensions Agency. The provisions are uncertain with regard to the value of the cash reimbursements and the period of time over which the contribution will be made.

245

16.1 Contractual Capital Commitments ‐ Group and Foundation Trust Contractual capital commitments at 31 March 2014 not otherwise included in these financial statements:

31 March 2014

31 March 2013

£000 £000 Property, plant and equipment 5,388 23,801Total 5,388 23,801*The above relates to the new Emergency Care Centre and the new Pathology Project. 16.2 Events after the Reporting Period ‐ Group and Foundation Trust There were no events after the reporting period having a material effect on the accounts. 16.3 Contingent Liabilities ‐ Group and Foundation Trust

31 March 2014

31 March 2013

£000 £000 Gross estimated value of Non‐Clinical Liabilities (143) (74)Expected recoverable amount 0 0Net value contingent liabilities (143) (74)

The Employer Liability Contingency figure of £143k is provided by information received from the NHS Litigation Authority and the Foundation Trust's legal services department. 16.4 Related Party Transactions ‐ Group & Foundation Trust

Income Expenditure £000 £000

Value of transactions with related parties in 2013/14 : Department of Health 34 48Other NHS Bodies 193,929 8,754Charitable Funds 0 0Other 0 0NHS Shared Business Services 0 0Total 193,963 8,802Value of transactions with related parties in 2012/13 : Department of Health 55 47Other NHS Bodies 181,584 8,862Charitable Funds 0 0Other 0 0NHS Shared Business Services (Pensions) 0 0Total 181,639 8,909

246

16.5 Related Party Balances Receivables Payables

£000 £000 Value of balances (other than salary) with related parties in relation to doubtful debts at 31 March 2014 0 0Value of balances (other than salary) with related parties in respect of doubtful debts written off in the year at 31 March 2014 0 0Value of balances with other related parties in 2013/14 : Department of Health 0 620Other NHS Bodies 9,811 2,473Charitable Funds 30 0Other 152 0NHS Shared Business Services 0 0Total 9,993 3,093 Value of balances (other than salary) with related parties in relation to doubtful debts at 31 March 2013 0 0Value of balances (other than salary) with related parties in respect of doubtful debts written off in the year at 31 March 2013 0 0Value of balances with other related parties in 2012/13: Department of Health 30 1Other NHS Bodies 4,250 1,855Charitable Funds 29 3Other 250 0Total 4,559 1,859

16.6 Related Party Transactions Gateshead Health NHS Foundation Trust is required under IAS 24 to disclose material transactions undertaken with related parties. During the year none of the Board Members or members of the key management staff or parties related to them has undertaken any material transactions with the Trust. The Foundation Trust has also received revenue and capital payments from the Gateshead Health NHS Foundation Trust charitable fund. All of the Trustees of the charity are members of the Trust Board. The total value of Funds Held on Trust at 31st March 2014 was £1,861,279. The Foundation Trust owed the Charity £1,613 and the Charity owed the Foundation Trust £29,996. The total value of transactions during the year between the related parties was £46,696 (2012/13 total value of £36,955).

247

Note 17. Financial Assets / Liabilities ‐ Group and Foundation Trust Note 17.1 Financial assets by category Group Foundation Trust

Total Loans and receivables Total

Loans and receivables

Assets as per Statement of Financial Position £000 £000 £000 £000 Trade and other receivables excluding non financial assets ‐ Note 10 11,325 11,325 11,296 11,296

Cash and cash equivalents at bank and in hand ‐ Note 12 15,004 15,004 14,553 14,553

Total at 31 March 2014 26,329 26,329 25,849 25,849Trade and other receivables excluding non financial assets 6,123 6,123 6,123 6,123

Cash and cash equivalents (at bank and in hand) 21,538 21,538 21,538 21,538Total at 31 March 2013 27,661 27,661 27,661 27,661

Note 17.2 Financial liabilities by category Group Foundation Trust

Total

Other financial liabilities Total

Other financial liabilities

Liabilities as per Statement of Financial Position £000 £000 £000 £000 Borrowings excluding Finance lease liabilities ‐ Note 14 22,000 22,000 22,000 22,000

Obligations under finance leases ‐ Note 14 121 121 121 121NHS Trade and other payables excluding non financial liabilities ‐ Note 13 18,542 18,542 18,080 18,080

Other Financial Liabilities 0 0 0 0Provisions under contract 3,387 3,387 3,387 3,387Total at 31 March 2014 44,050 44,050 43,588 43,588Borrowings excluding Finance lease liabilities 4,600 4,600 4,600 4,600Obligations under finance leases 199 199 199 199NHS Trade and other payables excluding non financial liabilities ‐ Note 13 18,638 18,638 18,614 18,614

Other Financial Liabilities 370 370 370 370Provisions under contract 2,775 2,775 2,775 2,775Total at 31 March 2013 26,582 26,582 26,558 26,558

17.3 Liquidity Risk The Foundation Trust's net operating costs are incurred under annual legally binding contracts with local Clinical Commissioning Group, which are financed from resources voted annually by Parliament. The Trust also finances its Capital expenditure from retained depreciation and accumulated surpluses. The Foundation Trust has a loan financed by the Foundation Trust Financing Facility for £22m to partly fund the construction of the Emergency Care Centre. A further £12m has been approved as a PDC advance to fund the Pathology Centre of Excellence (£10,676k currently drawn down). A further PDC advance was made for £211k against the transfer of Regional Medical Physics Equipment to the FT. Also PDC of £650k drawdown against the Nurse bedside Observation project and £569k against the Safer Hospitals Safer Wards allocation for e‐prescribing. 17.4 Interest Rate Risk 59% of the Trust's current financial assets consist of cash which carries a floating rate of interest. Finance Lease arrangements are subject to a fixed rate of interest. The current FTFF loan of £22m is subject to an interest repayment rate of 3.78% 17.5 Foreign Currency Risk The Trust has no foreign currency income or expenditure.

248

Note 18. Fair Values ‐ Group and Foundation Trust Note 18.1 Fair values of financial assets Group

31 March 2014

31 March 2014

31 March 2013

31 March 2013

Book Value Fair value Book Value Fair value £000 £000 £000 £000

Cash & cash equivalents 15,004 15,004 21,538 21,538 Current Receivables 10,137 10,137 4,876 4,876 Non Current Receivables a 1,188 1,188 1,247 1,247 Total 26,329 26,329 27,661 27,661

Foundation Trust 31 March 2014

31 March 2014

31 March 2013

31 March 2013


Cash & cash equivalents 14,553 14,553 21,215 21,215 Current Receivables 10,108 10,108 4,876 4,876 Non Current Receivables a 1,188 1,188 1,247 1,247 Total 25,849 25,849 27,338 27,338

Note 18.2 Fair values of financial liabilities Group

31 March 2014

31 March 2014

31 March 2013

31 March 2013


Non current Payables Lennartz b 462 462 721 721Provisions under Contract c 3,387 3,387 2,775 2,775Obligations under finance leases ‐ Note 14 121 121 199 199Trade & Other Payables 17,634 17,634 17,917 17,917Loans 22,000 22,000 4,600 4,600Total 43,604 43,604 26,212 26,212 Foundation Trust

31 March 2014

31 March 2014

31 March 2013

31 March 2013


Non current Payables Lennartz b 462 462 721 721Provisions under Contract c 3,387 3,387 2,775 2,775Obligations under finance leases ‐ Note 14 121 121 199 199Trade & Other Payables 17,618 17,618 18,263 18,263Loans 22,000 22,000 4,600 4,600Total 43,588 43,588 26,558 26,558

a This relates to a long term finance lease of a property to another NHS body. b The Trust carries a long term creditor for the repayment of VAT under the Lennartz ruling of the European Court of

Justice. This amount is not subject to interest and was repayable over ten years of which the Foundation Trust has three years to pay.

c Fair value is not significantly different from book value since, in the calculation of book value, the expected cash flows have been discounted where appropriate using the discount rates published and mandated by HM Treasury.

249

Note 19. Third Party Assets The Trust held £312 cash at bank and in hand at 31/03/14 (£14,387 at 31/03/13) which relates to monies held on behalf of patients. This has been excluded from the cash at bank and in hand figure reported in the accounts. Note 20. Public Dividend Capital Dividend The Trust is required to absorb the cost of capital at a rate of 3.5% of average relevant net assets. The resulting calculation of PDC (Public Dividend Capital) dividend, totalling £2,709,000 was calculated on the average relevant net assets of £77,423,000. The outturn PDC dividend was £2,774,000 which is included in the accounts and results in a carry over payment of £65k on the next year's collection from the Department of Health. Note 21. Losses and Special Payments Group and Foundation Trust NHS Foundation Trusts are required to follow the guidance issued by the Department of Health in accounting for losses and special payments: • These are items that Parliament would not have contemplated when it agreed funds for the health service or

passed legislation. • By their nature they are items that ideally should not arise. • They are divided into different categories, which govern the way each individual case is handled.

1 April 2013 ‐ 31 March 2014

1 April 2012 ‐ 31 March 2013

Ref. Category of loss / special payment

Number of cases

Value of cases

Number of cases

Value of cases

£000 £000 Losses 1b Losses of cash due to overpayment of salaries etc. 17 2 6 21c Losses of cash due to other causes 2 0 0 03a Bad debts and claims abandoned – private patients 5 2 21 63b Bad debts and claims abandoned – overseas visitors 10 8 7 73c Bad debts and claims abandoned – other 188 14 479 204a Damage to buildings, loss of equipment and

property due to theft, fraud etc 1 2 0 0

4b Damage to buildings, loss of equipment and property due to other causes

1159 50 33 0

Total Losses 1382 78 546 35Special Payments 7a Ex‐gratia payments for loss of personal effects 34 15 22 47c Ex‐gratia payments for personal injury with advice 4 33 7 53Total Special Payments 38 48 29 57Total Losses and Special Payments 1420 126 575 92

The above values have been calculated on an accruals basis whereby expenditure is recognised in the period in which the associated liability was incurred.

250

22 Charitable fund reserve The Trust is the corporate trustee to Gateshead Health NHS Foundation Trust Charitable Fund. The Trust has assessed its relationship to the charitable fund and determined it to be a subsidiary in accordance with IAS 27, because the Trust has the power to govern the financial and operating policies of the charitable fund so as to obtain benefits from its activities for itself, its patients or its staff. Prior to 2013/14 the Treasury had directed that IAS 27 should not be applied to NHS Charities, and therefore the FT ARM did not require the Trust to consolidate the charitable fund. This has been applied as a change in accounting policy, resulting in a prior period adjustment. The main financial statements disclose the Trust's financial position alongside that of the group (which comprises the Trust, subsidiary and charitable fund). The effect of the prior period adjustment on the prior year's financial statements can be seen from the summarised Statement of Financial Activities and Statement of Financial Position below: Gateshead Health NHS Foundation Trust Charity ‐ Summary Statement of financial activities;

Year ended 31 March 2014

Intra‐group eliminations

Year ended 31 March 2013


£000' £000' £000' £000' Donated income 164 0 159 0 Income from legacies 326 0 100 0 Investment income 48 0 47 0 Total incoming resources 538 0 306 0 Patients' welfare and amenities 230 82 0 Staff welfare and amenities 66 78 0 Medical research 40 ‐ 0 Contributions to the Foundation Trust 17 ‐17 8 ‐8 Governance costs 6 5 0 Total outgoing resources 359 ‐17 173 ‐8 Unrealised gain on investments 23 0 119 0 Net incoming resources 202 17 252 8

251

Gateshead Health NHS Foundation Trust Charity ‐ Summary Statement of financial position;

As at 31

March 2014Intra‐group eliminations

As at 31 March 2013


As at 1 April 2012


£000' £000' £000' £000' £000' £000' Investments 1,482 0 1,363 0 1,319 0 Receivables 3 0 9 ‐3 7 ‐4 Cash 451 0 324 0 140 0 Payables ‐75 59 ‐35 11 ‐57 32 Total net assets 1,861 59 1,661 8 1,409 28 Represented by: Unrestricted funds 1,258 0 1,128 0 992 0 Restricted funds 564 0 494 0 383 0 Endowment funds 39 0 39 0 34 0

1,861 0 1,661 0 1,409 0 The total funds are represented in the Group accounts as Charitable Funds Reserve. Restricted funds are funds donated for a specific purpose. Unrestricted funds may be designated for a particular area but are not restricted on the purpose of expenditure. Endowment funds relate to capital funds where the charity does not hold the power to convert capital into income. power to convert the capital into income. The capital must generally be held indefinitely; the income generated by the investment of the funds can be used for charitable purposes at the discretion of the Trustees.

252

22 Charitable fund reserve (continued) As at 31 March

2013 Adjustment As restated at 31 March 2013

As at 1 April 2012 Adjustment

As restated at 1 April 2012

£000' £000' £000' £000' £000' £000' Non‐current assets Property, plant and equipment 116,029 116,029 105,770 105,770 Other Investments (Charitable) 0 1,363 1,363 0 1,319 1,319 Trade and other receivables 2,155 2,155 3,441 3,441 Total non‐current assets 118,184 119,547 109,211 110,530 Current assets Inventories 2,120 2,120 2,117 2,117 Trade and other receivables 7,120 6 7,126 6,412 7 6,419 Other financial Assets 0 0 0 0 Cash and cash equivalents 21,215 323 21,538 20,823 140 20,963 Total current assets 30,455 30,785 29,352 29,499 Current liabilities Trade and other payables (17,893) ‐24 (17,917) (14,494) ‐57 (14,551) Borrowings (103) (103) (103) (103) Provisions (817) (817) (963) (963) Other liabilities (3,738) (3,738) (5,348) (5,348) Total current liabilities (22,551) (22,575) (20,908) (20,965) Total assets less current liabilities 126,087 1668 127,757 117,655 1,409 119,064 Non‐current liabilities Trade and other payables (721) (721) (981) (981) Borrowings (4,696) (4,696) (2,200) (2,200) Provisions (2,327) (2,327) (2,742) (2,742) Total non‐current liabilities (7,744) (7,744) (5,923) (5,923) Total assets employed 118,343 120,012 111,732 113,141 Financed by taxpayers' equity Public Dividend Capital 103,927 103,927 99,515 99,515 Revaluation Reserve 16,830 16,830 17,352 17,352 Charitable Fund Reserve 0 1668 1,661 0 1,409 1,409 Other Reserves 99 99 99 99 Income & Expenditure Reserve (2,513) 8 (2,505) (5,234) (5,234) Total taxpayers' equity 118,343 120,012 111,732 113,141

253

Contact Information

Trust Secretary If you would like: to view the register of Board of Directors interests to contact the Chairman or any of the Board of Directors detailed information about Board of Directors meetings of Gateshead Health NHS Foundation Trust, which are open to the public. Details of meetings are displayed in all Trust premises, clinics, health centres and libraries throughout Gateshead and on the Trust’s website

to contact the Chief Executive’s office for more information or if you have any comments further copies of this report or copies of the full accounts

Telephone: 0191 4453712 Email: [email protected] Website: www.qegateshead.nhs.uk

Membership Co‐ordinator If you would like: to become a member of Gateshead Health NHS Foundation Trust to contact any of the governors to view the register of Council of Governors interests to view the register of Members detailed information about the meetings of the Council of Governors Write to: Freepost NAT14353 Gateshead Health NHS Foundation Trust Queen Elizabeth Hospital Sheriff Hill Gateshead, NE9 6BR Telephone: 0191 445 3713 Fax: 0191 482 6001 Email: [email protected]

Patient Advice and Liaison Service (PALS) If you would like information, support or advice about the Trust’s services. Telephone: (freephone) 0800 953 0667 Fax: 0191 445 3542 Direct Dial: 0191 445 6129 Email: [email protected] Gateshead Health NHS Foundation Trust Trust Headquarters Queen Elizabeth Hospital Gateshead, NE9 6SX



Membership Strategy Sub Group Update

1. Current Membership

Information on membership numbers is presented at each meeting and reviewed by the group. This includes breakdowns by age, gender and ethnicity. The total number of members at 31st August 2014 was 12,702; 12,416 public and 286 patient members. A graph showing membership totals is overleaf as Appendix 1.

2. Recent Work Unfortunately the meeting of the group scheduled for 11th September 2014 did not go ahead as the quorum attendance of three public governors was not met. However, the group has continued to take part in the following activities: • appointed Dr F Kanu, public governor as the group’s new Chairman • organised a Medicine for Members event in the Western constituency • provide regular updates to the Council of Governors on governor activity and feedback

from online survey • continued with recruitment in OPD • promoted membership in the Women’s Health Clinic

3. Next Steps/Future Plans The next steps/future plans for the group are to: • encourage all members of the Council of Governors to become involved in recruitment • continue to work with all governors towards the objectives and actions detailed in the

Membership Strategy • continue to promote membership in the QE Outpatients department • begin attending local engagement events • review the terms of reference for the group

Mrs D Atkinson Trust Secretary

Appendix 1

2306

6393

3618

99286

0

1000

2000

3000

4000

5000

6000

7000

Eastern Central Western Out of Area Patient

Membership by Constituency(at 31st August 2014)



Governor Activities

1. Introduction

Data for the report has been compiled from attendance at events and meetings and from the online feedback form.

The time period of the activities below covers 1st May 2014 to 17th September 2014 inclusive.

2. Governor Activities

During the period, 39 survey responses were received from governors after attending an event or meeting. The feedback was as follows:

3. Recommendation

The Council of Governors is asked to note this summary and the activities report attached as Appendix 1.

Debbie Atkinson Trust Secretary

Appendix 1

Governor Activities Public and Staff

Governor Name Activity Date

Eileen Adams

Membership Strategy Sub Group 08/05/2014 Volunteers Evening 12/05/2014 Recruitment at Trauma Clinic 15/05/2014 Recruitment at OPD 29/05/2014 Recruitment at OPD 19/06/2014 Medicine for Members – Audiology 02/07/2014 Governors’ Development Day 09/07/2014 Community Engagement – St Peter’s Church 14/07/2014 Recruitment at OPD 14/08/2014 Recruitment at Women’s Health 18/08/2014 Recruitment at OPD 26/08/2014 Visit – Catering 02/09/2014

John Bolam

Volunteers Evening 12/05/2014 Wayfinding Open Event 26/06/2014 Governors’ Development Day 09/07/2014 Visit – Radiology 26/08/2014 Governors’ Workshop – Communication Skills 10/09/2014

Tom Bryden

Membership Strategy Sub Group 08/05/2014 Volunteers Evening 12/05/2014 Wayfinding Open Event 26/06/2014 Governors’ Development Day 09/07/2014 Community Engagement – Crawcrook Fair 02/08/2014

Faye Butler Nursing Conference 30/05/2014 Business and Service Development Committee 05/06/2014

Alan Dougall

Membership Strategy Sub Group 08/05/2014 Volunteers Evening 12/05/2014 Human Resources Committee 02/06/2014 PLACE Inspection 04/06/2014 Governors’ Development Day 09/07/2014 Board of Directors 23/07/2014 Human Resources Committee 04/08/2014 Visit – Breast Screening Unit 19/08/2014 Visit – Radiology 26/08/2014

Anna Ellinson

Volunteers Evening 12/05/2014 Dementia Care Steering Group 13/05/2014 Dementia Care Steering Group 08/07/2014 Governors’ Development Day 09/07/2014 Governors’ Workshop – Communication Skills 10/09/2014

Sheila Gallagher

Interview Panel – Non‐Executive Director 14/05/2014 Governors’ Development Day 09/07/2014 Visit – Pathology Centre of Excellence 16/09/2014 Governors’ Workshop – Communication Skills 10/09/2014


Alison Griniezakis

Volunteers Evening 12/05/2014 Medicine for Members – Audiology 02/07/2014 Governors’ Development Day 09/07/2014 Human Resources Committee 04/08/2014 Visit – Pathology Centre of Excellence 16/09/2014

Brian Hewitt

Membership Strategy Sub Group 08/05/2014 Volunteers Evening 12/05/2014 Patient Experience and Dignity Committee 12/05/2014 Recruitment at Felling Health Centre 20/05/2014 Work Attire Group 27/05/2014 Safeguarding Committee 18/07/2014 Work Attire Group 26/08/2014 Visit – Catering 02/09/2014 Patient Experience and Dignity Group 08/09/2014 Governors’ Workshop – Communication Skills 10/09/2014 Visit – Pathology Centre of Excellence 16/09/2014

Paul Hopkinson

Volunteers Evening 12/05/2014 Interview Panel – Non‐Executive Director 14/05/2014 Business and Service Development Committee 05/06/2014 Board of Directors 25/06/2014

Margaret Jobson

Patient Experience and Dignity Committee 12/05/2014 Volunteers Evening 12/05/2014 Recruitment at Trauma Clinic 15/05/2014 Recruitment at Felling Health Centre 20/05/2014 Medicine for Members – Blood Pressure 21/05/2014 Recruitment at OPD 29/05/2014 Recruitment at OPD 19/06/2014 Wayfinding Open Event 26/06/2014 Medicine for Members – Audiology 02/07/2014 Governors’ Development Day 09/07/2014 Recruitment at OPD 17/07/2014 Recruitment at OPD 14/08/2014 Recruitment at Women’s Health 18/08/2014 Visit – Radiology 26/08/2014 Recruitment at OPD 26/08/2014

Francis Kanu

Membership Strategy Sub Group 08/05/2014 Medicine for Members – Blood Pressure 21/05/2014 Board of Directors 25/06/2014 Wayfinding Open Event 26/06/2014 Medicine for Members – Audiology 02/07/2014 Governors’ Development Day 09/07/2014 Community Engagement – St Peter’s Church 14/07/2014 Patient, Quality, Risk and Safety Committee 18/07/2014 Board of Directors 23/07/2014

Jacqueline Lockwood

Patient, Quality, Risk and Safety Committee 16/05/2014 Board of Directors 25/06/2014 Governors’ Development Day 09/07/2014 Patient, Quality, Risk and Safety Committee 18/07/2014 Community Engagement – Crawcrook Fair 02/08/2014 Governors’ Workshop – Communication Skills 10/09/2014


Lynn Ritchie

Corporate Induction 06/05/2014 Visit – Sunniside Unit and Cragside Court (via MHA) 27/06/2014 Medicine for Members – Audiology 02/07/2014 Governors’ Workshop – Communication Skills 10/09/2014

Ian Stafford Interview Panel – Non‐Executive Director 14/05/2014 Nursing Conference 30/05/2014

Christine Squires Medicine for Members – Blood Pressure 21/05/2014 Governors’ Development Day 09/07/2014

Mary Summers

Membership Strategy Sub Group 08/05/2014 Safeguarding Committee 23/05/2014 Wayfinding Open Event 26/06/2014 Medicine for Members – Audiology 02/07/2014 Governors’ Development Day 09/07/2014 Safeguarding Committee 18/07/2014 Community Engagement – Crawcrook Fair 02/08/2014 Visit – Pathology Centre of Excellence 16/09/2014

Carole Turnbull

Teresa Waring Membership Strategy Sub Group 08/05/2014 Interview Panel – Non‐Executive Director 14/05/2014

In addition, appointed governors have also been able to attend the following events:

Governor Name Activity Date Sarah Gascoigne Governors’ Development Day 09/07/2014

Ashok Kumar Governors’ Development Day 09/07/2014 Visit – Medicine and Jubilee Wing 09/09/2014 Visit – Pathology Centre of Excellence 16/09/2014



Q4 2013/14 Monitoring and 2014/15 Annual Plan Review of NHS Foundation Trusts

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PERFORMANCE REPORT

1. Purpose of the Report

This report provides an update on performance against national and local targets at the end of June 2014 and Quarter 1 providing a summary of: • Performance governance indicators measured in Monitor’s Regulatory Risk Assessment

Framework; • The position in relation to the Trust’s activity plan; • A summary of our current risks to performance; • Quarterly HR summary, and • A summarised Care Quality Commission (CQC) performance dashboard, appendix A.

2 Performance Executive Summary 2.1 Risk Assessment Framework

2.12 Access The data relating to cancer performance measures are still subject to patch wide validation and are therefore provisional at the time of writing this report. The quarterly performance position in the Risk Assessment Framework dashboard (figure 1) represents aggregate compliance at Trust level for all measures with service pressures in Lung, Urological and Gynaecological tumour sites. The Trust was compliant against the 4 hour A&E target in June, and Q1 with performance reported as 95.02% for type I activity and 96.68% for all types of activity. Despite on‐going data validation pressures the Trust achieved Trust level compliance in two of the three 18 week Referral to Treatment measures. The RTT measure for Admitted patients is still subject to data validation. Service line pressures continue in Trauma and Orthopaedics, General Surgery, Neurology and Gastroenterology. Actions plans are in place to reduce the DQ backlog on the Incomplete PTL and the Trust is implementing a plan to reduce the numer of patients waiting for treatment down to 16 weeks by the end of August. A weekly Patient Tracking List is also being submitted to Monitor and the CCG.

2.13 Outcomes There have been 2 incidences of Clostridium Difficile in Q1; both cases are currently under review to determine if they were attributed to a lapse in care and avoidable. The Trust is still within the quarterly allowance and is compliant with all outcome measures at the end of Q1.

2.2 Local HR Supporting Measures

At the end of June the Trust’s rolling 12 month sickness absence rate of 5.04% is higher than the internal target of 3.4%. Surgical Services and Medicine & Elderly Business Units remain the main outliers.

The proportion of bank usage has improved; in Q1 the total hours used reduced by 3% from the previous quarter. Q1 has also seen huge improvements in attendace rates at Corporate and Local Induction; Corporate induction attendance compliance rose from 89% to 93% whilst Local induction compliance improved from 87% to 93% from the previous quarter. The proportion of staff receiving mandatory training improved slightly in Q1 to 83% from 82% in Q4, and our compliance rates against the numer of staff eligible for PDP’s improved significantly from 77% in April to 83% at the end of June.

3 Summary

At the end of month 3 and Q1 the Trust is complaint with all measures in the Risk Assessment Framework, with the exception of the Admitted RTT 18 week measure. It is anticipated that this position will improve as data validation increases in time for DoH submission on the 17th July. The Board to Board performance Framework and supportive management and transformational improvement reviews will continue to provide focus and support strategies for delivery in key performance areas experiencing pressures. Resolution of the issues and sustainability going forward remain a high priority to the Trust.

4 Recommendations

The Board is requested to receive this report as assurance against the management of the governance indicators in the Risk Assessment Framework and local supporting measures of performance management.

Yvonne Ormston Deborah Renwick Deputy Chief Executive Strategic Head of Performance

1 Risk Assessment Framework Dashboard Targets – weighted 1.0 Target/ Trajectory Quarterly Target Q1

2014/15 Q2

2014/15 Q3

2014/15 Q4

2014/15 ACCESS Referral to Treatment Admitted 90% 89.4%

Referral to Treatment Non‐Admitted 95% 96.9%

Referral to Treatment Incomplete pathways 92% 94.1%

Total time in A&E ‐ 4 hours Type I 95% 95.02%

Total time in A&E ‐ 4 hours All Types 95% 96.68%

Maximum 62 day wait for first treatment

GP Referral 85% 86.8%

Screening 90% 95.5% Maximum waiting time of 31 day subsequent treatments for all cancers

Drugs 98% 100%

Surgery 94% 98.5%

Maximum waiting time of 31 days from diagnosis to treatment for all cancers

96% 100%

Maximum waiting time of 2 weeks from urgent GP referral for all urgent suspect cancer referrals

2ww 93% 93.6%

Breast 93% 93.7%

OUTCOMES Clostridium difficile Annual ceiling of 24 6 2

Minimising mental health delayed transfers of care (national reporting)

<=7.5% 0%

Data completeness: identifiers 97% 99.0%

Data completeness: outcomes for patients on CPA

50% 82.6%

Certification against compliance for access to healthcare for people with a learning disability

Yes/No Yes

Data Completeness: Community Dataset

RTT 50% 92.5% Referral information

50% 100%

Treatment Activity 50% 100%

(shadow monitoring) Patient ID 50% 93.1%

INTERNAL MONITORING ONLY

Quarterly Target

Q1 2014/15

Q2 2014/15

Q3 2014/15

Q4 2014/15

MRSA Objective Annual ceiling of 0

0

0

Figure 1 – Trust Risk Assessment Dashboard 2 Trust Activity Plan

The table below sets out the Trust’s position in relation to June (month 3). Further in‐depth analysis can be obtained from the Finance & Activity Report. Clinical Activity by point of delivery

Activity Plan June

Activity Actual June

% Difference

A&E attendances Day cases Elective –long stay Elective – Excess bed days Non elective Non elective – Excess bed days Outpatients – New Outpatients – Follow up Outpatients – Procedure

15,7185,9561,330252

6,7422,268

11,77231,7453,639

16,0066,3471,258167

6,6891,504

11,79232,4873,890

1.8%6.6%‐5.4%

‐33.7%‐0.8%

‐33.7%0.2%2.3%6.9%

Figure 2 – Trust Activity Plan

Headlines at the end of the year are: • Elective activity has underperformed against the annual plan by 5.4%; • Day case activity has over performed against the plan by 6.6%; • Non‐elective activity was 0.8% below plan; • New outpatient activity was marginally above plan; • Outpatient follow up activity was slightly above plan by 2.3%, and • A&E attendances were slightly above expected levels by 1.8%

3 Productivity & Efficiency The programme for Improving Clinical Performance continues to progress work in the following areas. Target 2012/13 2013/14 Q1

2014/15 Q2

2014/15 Q3

2014/15 Q4

2014/15

Elective Los 0.8 0.75 0.81 0.59

Non Elective Los 4.95 4.05 4.99 4.86

Day Case Rate 80% 79.12% 81.86% 83.48%

SDA Rate EL 75% 73.11% 78.5% 79.66%

SDA Rate NEL 48% 42.21% 44.18% 49.93%

Stroke Spelled Los Avg. 13 days 13.99 15.42 14.56

Target 2012/13 2013/14 Q1 2014/15

Q2 2014/15

Q3 2014/15

Q4 2014/15

Stroke Los Median 5 7 5 8

Critical Care Beds 12 12 12 12

Paediatric Beds 9 16 16 8

Cardiology 21 21 21 21

New OP DNA Rate 8.06% 7.01% 7.82%

New to Review Ratios 3.04 3.01 3.19

Figure 3 – ICP Metrics 4. Trust Performance 4.1 2 Week Waits ‐ Cancer Performance The White Paper ‘The New NHS – Modern, Dependable’ guaranteed that everyone with suspected cancer will be able to see a specialist within 2 weeks of their GP deciding that they need to be seen urgently upon requesting an appointment. Trusts are monitored monthly, quarterly and annually against this standard to ensure that no patient waits longer than necessary for access to specialist care. Our current performance of performance of 93.6% is above the tolerance of 93% although at the time of writing this report this information is still subject to change via internal validation processes. 4.2 A&E The Trust reported Q1 performance for type I activity at 95.02%, and all types of activity at 96.68%. The dashboard in figure 4 highlights the quarterly quality performance indicator breakdown for type I and all types of activity. Target /Trajectory Target Q1

2014/15 Q2

2014/15 Q3

2014/15 Q4

2014/15

A&E Clinical Quality: Total Time in A&E – 95th Percentile 4 hours 3 h 59 m

A&E Clinical Quality: Time to Initial Assessment ‐95th Percentile

15 mins 17 minutes

A&E Clinical Quality: Time to Treatment Decision – Median

60 mins 55 minutes

A&E Clinical Quality: Unplanned re‐attendance rate <5% 2.3%

A&E Clinical Quality: Left Without being seen <5% 2.6%

Figure 4 – A&E Quality Dashboard

4.3 18 Weeks ‐ Referral to Treatment 4.31 Measures & Performance These measures are assessed monthly (at specialty level), in the Local Contract with Commissioners and quarterly using aggregate Trust level data in the Risk Assessment Framework. The table below shows the national thresholds and GHNFT’s quarterly performance for 2014/15.

Completed Inpatient Pathways (Admitted Adjusted) %

Median Wait

95th percentile

National Thresholds 90% <11.1 <27.7 Total GHNT (all specialties) – Q1 89.4% 11.29 22.14 Total GHNT (all specialties) – Q2 Total GHNT (all specialties) – Q3 Total GHNT (all specialties) – Q4

Completed Outpatient Pathways (Non‐admitted) % Median 95th

percentile Wait National Thresholds 95% <6.6 <18.3 Total GHNT (all specialties) – Q1 96.9% 5.29 16.88 Total GHNT (all specialties) – Q2 Total GHNT (all specialties) – Q3 Total GHNT (all specialties) – Q4 Incomplete pathways (combined admitted and

non‐admitted) % Median Wait 95th percentile

National Threshold 92% <7.2 <36 Total GHNT (all specialties) – Q1 94.1% 6.24 19.16

Total GHNT (all specialties) – Q2

Total GHNT (all specialties) – Q3 Total GHNT (all specialties) – Q4 Figure 5 – RTT Measures & Performance The table above demonstrates that Trust performance is achieving expected levels for two of the three 18 week standards which are assessed quarterly in the RAF, however these will continue to be validated until the submission date. Monthly performance data in Q1 to date indicates monthly achievement across all specialties, with service line exceptions in the following measures: Admitted: General Surgery and Orthopaedics; Non Admitted: Urology, T&O, ENT, Gastroenterology and Neurology; Incompletes: Urology, T&O and Neurology RTT has become a national concern for NHS England, with more Trusts failing to deliver the Constitutional right for patients to receive treatment within 18 weeks. The Area Team have been asked to identify Trusts currently at risk. Gateshead has now been identified ‘at risk’ because of the concern around the volume of patients and clearance times; which were reported at 17.3 weeks. An action plan is in place to support PAS

improvements and targeted training to ultimately prevent data quality issues. Discussions are ongoing with the CCG. The Business Units have also been given additional internal funding to increase resources required to validate the Patient Tracking List. External funding has been allocated to reduce patients waiting down to 16 weeks by the end of August. Monitor require all Trusts to report via UNIFY a weekly PTL and have issued a ‘performance amnesty’ agasint the 3 RTT measures during the summer period. 4.4 Cancer 62 Day Treatment Targets The Trust is compliant with this measure for YTD performance; current performance is at 86.8%. 4.4.1 Pressures The quarterly performance position identifies Lung, Urological and Gynaecological tumour sites as having the highest level of breaches. 4.4.2 Mitigating Actions The cancer information team and the Business Units are proactively tracking ‘at risk’ patients to mitigate the risk of incurring further breaches. An action plan is in place to ensure remedial actions are timely and effective and we await RCA’s from Q1 to understand the current service pressures. The target is still at risk given the number of confirmed and potential breaches on the PTL. There is a chance however those delays in cancer treatments for patients on the PTL will transfer the delivery risk into Q2 or beyond. 4.5 Infection Prevention & Control 4.5.1 MRSA The Trust has reported no cases of MRSA so far in 2014/15 against a zero tolerance trajectory. This measure is excluded from the Risk Assessment Framework and is included in the CQC’s Intelligent Monitoring reports. 4.5.2 C.Difficile The Trust has reported 2 case of C.difficile against a trajectory of 6 in Q1 . The Annual trajectory for C difficile is 24. 4.6 Slot Issues The NHS Constitution guarantee to patients to be seen within 18 weeks still stands, and our performance in areas such as Choose and Book and becoming a hospital of choice are still dependent on short wait times for outpatients and surgery. The patient booking system ‘Choose & Book’ publicise specialty level RTT waiting‐times to help assist the public in their choice of hospital. Patients usually access secondary care (for the first time in the pathway) in either one of two routes, either a manual GP referral via paper/fax etc. or via the national electronic booking system, Choose and Book. The electronic option remains the favoured route for referrals into our hospital, accounting for circa 75% of our initial referrals. Access to first appointments, therefore remains an influential consideration when choosing an acute provider for care and treatment. The Trust monitors all referrals, particularly electronic slot requests resulting in an issue, where by the appointments were not fulfilled. These failed appointments generate an ‘issue’, which could potentially result in the patient being unable to access the provider of first choice. The chart below (figure 6) details the percentage of appointment slot issues from April 2013 to May 2014. The NHS e‐ Referrals Agency

(Choose & Book) have confirmed that this data will now be published 8 weeks in arrears, an update for June should be available in July’s performance report.

Figure 6 – Choose & Book Slot Issues 4.7 Cancelled Operations In June, 16 elective operations were cancelled during the month. The main reasons for cancellation were attributed to bed pressures, theatre list over‐runs and equipment issues. The Trust’s cancellation rate for June was 0.61%; Q1 to date performance stands at 0.74% which is slightly below the nationally agreed tolerance level of 0.8%.

Figure 7 – Cancelled Operations ‐ % of FFCE’s The graph above in figure 9 highlights the increasing trend over the last year, particularly identifying issues and pressures in the last 2 quarters of 2013/14 and into Q1 of this financial year. The main issues contributing towards the underperformance in Q1 are highlighted below in figure 10.

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Choose & Book Slot Issues

Slot issues

Target

0.0%0.2%

0.4%0.6%0.8%1.0%

1.2%1.4%

Apr

-13

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13

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-13

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-13

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15

Cancelled operations as % of FFCEs

Cancelled ops as % of elective FFCEs Target YTD Actual

Figure 8 – Reasons for cancelled operations Q1 The action plan for recovery and improvement is included within the Surgical Strategy. 4.8 Delayed Discharges/Transfers of Care Once a patient no longer requires hospital treatment, a patient should not continue to be in hospital waiting for arrangements to support the patient in their home environment to be put in place. Typically such arrangements can include allocation of care coordinator, housing, specialist placements etc. Unnecessary stays in hospital can make people more dependent, and increase the risk of care and social networks breaking down. Planning a patient’s discharge needs to start early, preferably shortly after admission. Decisions about complex discharges usually involve an agreement with the patient and their carer and are drawn up by the multidisciplinary team, considering the full range of a patient’s needs i.e. both health and social. Delays in discharge are monitored daily, with on‐going audit of the SITREP returns to ensure that reasons for delays are analysed and remedial action taken. The Trust usually (on average) reports around 30 delayed days for 6 patients per week. In Q1 2014/15 the Trust reported an average of 57 delayed days for 13 patients per week. The graph below demonstrates deterioration, via the upward trend continuing into Q1 2014/15.

Figure 9 – Delayed discharges The Trust has now established regular reviews with the Local Authority to manage performance and reduce delayed discharges; ensuring plans are in place to manage winter pressures.

Reasons for Cancelled operations Q1 2014‐2015

Equipment issues

Beds

No assistant available

Consultant unavailable

List overrun

Admin error

Pt cancelled medical reasons

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

08/04/12

08/05/12

08/06/12

08/07/12

08/08/12

08/09/12

08/10/12

08/11/12

08/12/12

08/01/13

08/02/13

08/03/13

08/04/13

08/05/13

08/06/13

08/07/13

08/08/13

08/09/13

08/10/13

08/11/13

08/12/13

08/01/14

08/02/14

08/03/14

08/04/14

08/05/14

08/06/14

Weekly delayed discharges as a percentage of occupied bedsApril 2012 ‐ June 2014

4.9 Diagnostic Waiting Times The Trust reports and measures current waiting times for patients still waiting for a diagnostic test at the end of the month. This information is split by number of weeks waiting, and by test. The waiting times reported are for those patients who have been referred for a test, but whose test had not taken place by the end of the reporting period. The six week diagnostic wait was initially introduced as a ‘milestone’ from March 2008 towards achieving the standard Referral to Treatment wait of 18 weeks by December 2008. The NHS Operating Framework, 2012/2013 introduced the expectation that less than 1 per cent of patients should wait six weeks or longer for a diagnostic test. The Trust achieved this target at a Trust level in May of 2014, the YTD performance stands at 99.78%. At the time of writing this report there were no reporting updates available for June due to the implementation of the new Radiology Information System. 5.0 Human Resources 5.1 Headcount/Full‐Time Equivalent The Trust headcount as at 30 June 2014 was 3567 and full time equivalent (fte) was 3116.03 which is a decrease compared to 31 March 2014 of 37 headcount and a reduction of 24.57 FTE respectively, despite 37 staff transferring into the Trust from the QE and Blaydon Walk in Centres. A number of leavers are those who were offered voluntary severance, and others have left as a result of the ongoing Pathology restructuring process. Otherwise the decrease is reasonably evenly split across a number of staff groups this quarter, including nursing, admin & clerical, pathology and senior medical & dental staff. It should be noted that the headcount and fte figures in this report will vary to those produced by Finance as these do not include recharges for junior doctors, consultants, secondees or bank and use whole calendar months whereas Finance include recharges and take information from a feed from Payroll, which occurs before the end of the month. 5.2 Turnover Turnover for the twelve months to 30 June 2014 was 12.07%, which is a slight increase from 10.21% for the twelve months to the end of March 2014. As in all previous reports, this figure excludes medical staff, as the high turnover of staff changing jobs as part of their training distorts the information. 5.3 Sickness Absence Figure 10 shows sickness absence over the 12 months to 31 May 2014. It can be seen that the rate was 5.04%

0

1

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3

4

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6

7

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14

Perc

enta

ge S

ickn

ess

Rat

e %

Month

Trend Analysis Sickness Rate Percentage in 2013/2014

Sickness Target (%)

Actual Sickness Rate (%)

Figure 10 – Sickness Absence Rates, monthly target monitoring For the period shown the main Clinical Business Units reported absence figures above the Trust target figure. Surgical Services reported 6.46% for the quarter, Medicine recorded 5.11%, with Assessment & Diagnostic Services making better progress at 4.22%. In terms of staff groups clinical support staff e.g. HCAs and Helpers continue to show consistently high levels of absence. The Attendance Policy and absence process will continue to be looked at as part of the Efficiency & Cost Savings Exercise with a view to ensuring all processes are in place and are being implemented appropriately and consistently by managers. The role of both Occupational Health and Personnel Teams will also be reviewed to ensure input is targeted to those areas requiring additional support. The pilot of the Attendance Management team has now commenced and a Steering Group has begun meeting to identify key areas of work to be addressed. Current areas of work involve addressing the situation regarding Additional Clinical Services staff, correlation between absence and bank usage, and highlighting the cost of absence to staff across the Trust to raise awareness and develop ownership of the situation. It is anticipated that a formal update will be presented to each meeting of the HR Committee for the duration of the pilot.

3

3.5

4

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Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May

Sicness Rate

Month

Comparison of Sickness Rates in 2013 /2014

2012/2013

2013/2014

Figure 11 – Sickness Absence Rates

Figure 11 gives a comparison of monthly Trust‐wide sickness rates for June 2012/May 2013 (blue/bottom line)and June 2013/May 2014 (red/top line). Although the rates were higher in the winter months of this year the position, comapred to last year has become much more stabilised, with a small but steady decrease beginning to show. Work is ongoing to maintain this position in the longer term. 5.4 Bank Usage The chart Nurse Bank Usage (figure 12) shows a decrease in usage of 1302.88 hours for the quarter ending 30 June 2014 (38791.25) compared to the previous quarter.

0

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Figure 12 ‐ Bank Staff Hours Worked 01 July 2013 – 30 June 2014 5.5 Equality & Diversity Monitoring Percentage figures by ethnic origin for the population of Gateshead are shown in Figure 13 along with the Trust workforce profile. Percentage of Population Ethnic Origin Gateshead Borough:

2011 census Trust staffing at 30 June 2014

A White ‐ British 94.1 93.55B White ‐ Irish 0.3 0.53White: other white 1.9 1.24D Mixed ‐ White & Black Caribbean 0.2 0.03E Mixed ‐ White & Black African 0.1 0.08F Mixed ‐ White & Asian 0.3 0.11G Mixed ‐ Any other mixed background 0.2 0.14H Asian or Asian British ‐ Indian 0.5 1.57J Asian or Asian British ‐ Pakistani 0.3 0.42K Asian or Asian British ‐ Bangladeshi 0.1 0.17Asian: any other Asian background 0.5 0.46M Black or Black British ‐ Caribbean 0 0.08N Black or Black British ‐ African 0.5 0.64P Black or Black British ‐ Any other Black background 0 0.14R Chinese 0.5 0.14Other ethnic group 0.5 0..70

Figure 13‐Equity & Diversity Monitoring Figure 14 shows the profile of the Trust workforce by broader categories.

95.32%

0.36%2.61%0.87%

0.14%

0.59%

0.11%

0.84%

Staff in Post by Ethnic Origin

White

Mixed

Asian or Asian British

Black or Black British

Chinese

Other

Not Stated

Figure 14 – Workforce ethnic categories

The age profile of the workforce, as shown in Figure 6, has 20.55% of the workforce 30 years old or younger (which is a slight decrease this quarter compared to 20.95% at 31 March 2014) and 30.00% aged over 50 years (a very slight increase this quarter compared to 29.77% in March 2014). Retirement regulations mean it is increasingly difficult to manage this position as the Trust can no longer require people to retire when they reach a certain age. It is therefore important that this situation is constantly monitored to understand the resulting impact of the age drift.

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Age Analysis as at 30 June 2014

Female

Male

Figure 15‐ Age Analysis

5.6 Corporate and Healthcare Professional Induction The percentage for Corporate Induction has increased to 93% (from 89% March 2014). The increase is due to the appointment of 16 newly qualified nurses who were appointed in March and their Induction could only be accommodated over the months of March and April. Figure 16 shows the number of staff who have completed Corporate Induction and Healthcare Professional Induction (if applicable). Those not required to complete this induction are:

• Internal movers within the Trust • Secondary post holders (e.g. an existing nurse working on the Bank) • Declined the post (although were included in the new starters list) • Left the Trust • Employed for less than one month with the Trust (e.g. students, work experience)

Month OD and Training Figures and Information

Eligible Completed Within 8 Weeks % Completed % Within 8 Weeks

July 19 19 18 100 95 August 37 37 37 100 100 September 56 53 52 95 91 October 41 41 41 100 100 November 25 23 19 92 76 December 22 20 18 91 82 January 16 15 15 94 94 February 19 18 18 95 95 March 32 31 30 97 94 April 18 13 13 72 72 May 20 20 20 100 100 June 24 18 18 75 86 Total 330 308 299 93 91 Figure 16 ‐ Corporate and Healthcare Professional Induction 2013 ‐ 2014 5.7 Local Induction Local Induction has continued to increase to 93% from 87% (March 2014). The percentage completed within 28 days of starting has also increased to 45% from 38% (March 2014). Figure 17 shows the number of local induction sign off sheets returned. This figure covers from 01 Jul 2013 – 30 Jun 2014.

Division Eligible Completed Within 2 Weeks % Completed % Within

28 Days Assessment & Diagnostic Services 84 78 45 93 54

Chief Executive 1 1 0 100 0 Estates & Facilities 33 32 25 97 76

Division Eligible Completed Within 2 Weeks % Completed % Within

28 Days Finance & Information 19 19 8 100 42 Health Development 6 5 4 83 67 Medicine & Elderly 110 103 41 94 37 Nursing & Midwifery 7 7 1 100 14 Surgical Services 48 42 15 88 31 Totals 308 287 139 93 45 Figure 17 – Local Induction Junior Doctors Figures 18 and 19 show the Trust intake of junior doctors from 01 Apr 2013 – 31 Mar 2014 and the percentage of those who have successfully completed their Trust and Local Induction. Junior Doctors Generic Induction has fallen to 83% (97% March 2014). Local Induction has improved to 83% (62% March 2014) for the most recent intake. To continue to drive improvement the Medical Education Team will be implementing a new process from the next intake,(4th August 2014), where no study leave will be authorised for Junior Doctors unless they have completed both Generic and Local induction.

Junior Doctors Generic Induction Eligible

New Starters 2013 ‐ 2014

Completed Within 8 Weeks % Completed % Within 8 Weeks

July ‐ Sept 137 120 120 88 88

Oct ‐ Dec 11 11 11 100 100

Jan ‐ Mar 39 38 38 97 97

April ‐ June 12 10 7 83 58

Figure 18 – Junior Doctors Generic Induction

Junior Doctors Local Induction Eligible

New Starters 2013 ‐ 2014

Completed Within 2 Weeks

% Completed % Within 2 Weeks

July ‐ Sept 137 88 87 64 64

Oct ‐ Dec 11 7 7 64 64

Jan – March 39 24 24 62 62

April ‐ June 12 10 10 83 83

igure 19 – Junior Doctors Local Induction 5.8 Mandatory Training Mandatory Training continues to be offered on a face‐to‐face and e‐learning basis. The overall percentage of staff trained has remained high at 83% (82% March 2014)

Figure 20 shows the current percentage of staff within the organisation who have successfully completed their Mandatory Training either face‐to‐face or via e‐learning in the last 12 months (1 July 2013 – 30 June 2014). The reasons that staff are not required or are unable to complete mandatory training include:

• Long Term Sick • Maternity Leave • External Secondment

However if a member of staff has been trained and is currently “Live” they will still be counted as “Eligible” and “Live MT” until their training expires, when they will be removed from “Eligible”

Figure 20 – Mandatory Training 5.9 Personal Development Plans The percentage of PDPs has increased significantly again to 83% from 77% (April 2014) Figure 21 shows the number of live PDPs reported to OD & Training from 01 Jul 2014 – 30 Jun 2014.

Figure 21 – PDP’s

Divisions Eligible MT Count Percentage

Assessment & Diagnostic Services 754 612 81.2Chief Executive 24 12 50Estates & Facilities 417 350 83.9Finance & Information 165 135 81.8Health Development 83 73 88Medicine & Elderly 760 629 82.8Nursing & Midwifery 76 63 82.9Surgical Services 706 618 87.5Total 2985 2492 83.48

Division Eligible PDPCount Lapsed No PDP Percentage

Assessment & Diagnostic Services 804 634 122 48 78.9Chief Executive 24 16 6 2 66.7Estates & Facilities 443 371 64 8 83.7Finance & Information 181 124 47 10 68.5Health Development 84 77 6 1 91.7Medicine & Elderly 848 769 66 13 90.7Nursing & Midwifery 83 66 14 3 79.5Surgical Services 731 596 113 22 81.5Total 3198 2653 438 107 82.96

17

Appendix A CQC – Performance Indicator Director

Lead Monitor Risk Rating

Target 2014/15

Q1 Q2 Q3 Q4 Year 2014/15

Anticipated Year End

National Commitments Data Quality for Ethnic Group JC >=85% 86.31% 86.31% Delayed Transfers of Care YO <=3.5% 2.23% 2.23% 4 hour Maximum Wait (Type I) CH >=95% 95.02% 95.02% 4 hour Maximum Wait (All Types) CH >=95% 96.68% 96.68% 2 Week Wait for RACP CH >=98% 99.4% 99.4% Cancelled Operations – 28 days Admitted 28 days SA

<=0.8% 0.74% 0.74% >=95% 100% 100%

National Priority Indicators Breast Feeding Initiative SA DRAFT >66.2% 69.18% 69.18% Smoking During Pregnancy SA DRAFT <16.78% 17.06% 17.06% Experience of Patients GMac Inpatient Survey/Friends & Family Test Participation in Heart Disease Audits GMac To be confirmed

Engagement in Clinical Audits GMac To be confirmed

Stroke Care 90% on stroke Unit CH DRAFT 80% 90.4% 90.4% % Patients with TIA treated <24 hours CH DRAFT 60% 50% 50% Maternity – Data Quality Indicators SA DRAFT <=15% 0.16% 0.16% MRSA bacteraemia GMac 1.0 0 0 0 MSSA GMac 3 3 E Coli (Data collection started June 2011) GMac 40 40

Clostridium Difficile Incidence GMac 1.0 24 2 2 18 Weeks Admitted within 18 weeks CH/CC/SA 1.0 > = 90% 89.4% 89.4% 18 Weeks Non Admitted within 18 weeks

CH/CC/SA 1.0 > = 95% 96.9% 96.9% 18 weeks Incomplete pathways within 18 weeks

CH/CC/SA 1.0 > = 92% 94.1% 94.1%

2 Week Wait Cancers GMac 0.5 >=93% 93.6% 93.6%

18

CQC – Performance Indicator Director Lead

Monitor Risk Rating

Target 2014/15

Q1 Q2 Q3 Q4 Year 2014/15


2 Week Wait Breast Symptoms GMac >=93% 93.7% 93.7% 31 Day diagnosis to treatment GMac 0.5 >=96% 100% 100% 31 Day diagnosis to treatment Drugs GMac

1.0 >=98% 100% 100%

31 Day diagnosis to treatment Surgery GMac >=94% 98.5 % 98.5%

62 Day Referral to treatment GMac 1.0

>=85% 86.8% 86.8% 62 Day Referral to treatment screening GMac >=90% 95.5% 95.5% 62 Day Referral to treatment upgraded GMac Shadow >=94% 80.0% 80.0% Time in A&E (95th percentile) CH 1.0 4 hours 3h 59m 3h 59m A&E Time to Initial Assessment CH 0.5 15 minutes 17 mins 17 mins A&E Time to treatment decision CH 0.5 60 minutes 55 mins 55 mins A&E Unplanned Re‐attendance Rate CH 0.5 <5% 2.3% 2.3% A&E Left without being seen CH 0.5 <5% 2.6% 2.6%

A&E Ambulatory Care Conditions CH

Cellulitis – 31.6% DVT – 36.4%

Cellulitis – 31.6%

DVT – 36.4%

Mental Health Data Completeness – identifiers CH 0.5 97% 99.0% 99.0% Mental Health Data Completeness – outcomes CH 0.5 50% 82.6% 82.6% Mental Health Delayed Discharges National Reporting CH 1.0 7.5% 0% 0%

MRSA Elective Screening GMac >100% 197.07% 197.07% Community dataset Data Completeness – Referral to treatment SA 1.0 50% 92.5% 92.5% Community dataset Data Completeness – Referral SA 1.0 50% 100% 100% Community dataset Data Completeness – Treatment activity SA 1.0 50% 100% 100%

19

Local Indicators Director

Lead Monitor Risk Rating

Target 2014/15

Q1 Q2 Q3 Q4 Year 2014/15


18 week RTT Admitted 95th Percentile CH/CC/SA <23 weeks 22.14 22.14 18 week RTT Admitted Median CH/CC/SA <11.1 11.29 11.29 18 week RTT Non Admitted 95th Percentile

CH/CC/SA <18.3 weeks 16.88 16.88

18 week RTT Non Admitted Median CH/CC/SA <6.6 5.29 5.29 RTT All specialties achieving % standards

CH/CC/SA

N/A All Specialties

Gen Surg, Urol, ENT, T&O, Gastro and

Neurology

Gen Surg, Urol, T&O, ENT, Gastro

and Neurology

Patients Waiting > 26 weeks CH/CC/SA N/A

332 (27 over

52) 332

(27 over 52)

Diagnostics Waiting Times CC N/A 99% 99.78% 99.78% Slot Issues CH/CC/SA N/A 4% 18.5% 18.5% Mixed Sex Accommodation breaches CH/SA N/A 0 tolerance 0 0



Election Timetable 2014

1. Elections 2013

The process for the annual elections to the Council of Governors will commence on 15th October 2014.

2. Positions

There will be eight governor positions to vote for: • 3 x Staff Governors • 2 x Public Governors for Central Gateshead • 2 x Public Governors for Western Gateshead • 1 x Patient Governor

As with previous elections, anyone wishing to be nominated for election as a governor for the first time must attend a governor briefing event. The event is being held on Thursday 9th October 2014.

Current governors whose tenure ends on 4th January 2015 will automatically be sent a nomination pack, unless they have advised the Membership Office of their intention not to stand for re‐election. They will not be required to attend a governor briefing event.

3. Schedule of Key Dates

Proceeding Date Notice of election issues 15th October 2014 Deadline for receipt of nominations by the returning officer 30th October 2014 Publication of statement of nominated candidates 31st October 2014 Final day for candidate withdrawals from election 4th November 2014 Notice of the poll 18th November 2014 Voting packs delivered to qualifying members 19th November 2014 Close of the poll 9th December 2014 Results declared 10th December 2014

4. Recommendation

The Council of Governors is asked to note the key dates and receive the report for information. Joanne Williamson Membership Co‐ordinator

1



Audit Committee Annual Report 2013/14

1. Introduction

Foundation Trusts establish their governance framework in line with Monitor’s Code of Governance. This Code of Governance requires that the Trust establish an independent Audit Committee as a central means by which a Board ensures effective internal control arrangements are in place. The Committee’s primary role is to conclude upon the adequacy and effective operation of the organisation’s overall internal control system. In performing that role, the Committee’s work predominantly focuses upon the framework of risks, controls and related assurances that underpin the delivery of the organisation’s objectives. Whilst it is clearly the job of the Executive Directors and the Accountable Officer to establish and maintain proper processes for governance, the Audit Committee independently monitors, reviews and reports to the Board on those processes and, where appropriate, facilitates and supports effective delivery. Not all assurances can be monitored in detail by the Audit Committee therefore the Committee relies on assurances from the Patient Quality Risk and Safety Committee (PQRS), the Business and Services Development Committee, the Finance Committee and the Human Resources Committee which include representative members from the Audit Committee. This report sets out how the Committee has met its Terms of Reference and fulfilled the role set out above in relation to the financial year ended 31 March 2014.

2. Work undertaken through the year 2.1 Governance, Risk Management and Internal Control

The membership and input into the Audit Committee during 2013/14 was stable. Kathryn Larkin‐Bramley remained as Chair throughout the year and there were no changes to Executive Directors or audit arrangements. Attendance at the Audit Committee by Non‐Executive Directors was as follows: Member Attendance at Meetings Chairman – Mrs K Larkin Bramley 5/5 Mr M Brown 2/5 Dr A Fairbairn 3/5 Mr F Major 4/5

The Trust is fully compliant with the registration requirements of the Care Quality Commission (CQC) and maintained its current status as registered without conditions through 2013/14. The CQC has not taken enforcement action against the Trust during 2013/14. There are processes within the Trust, including a CQC Steering Group, to monitor

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ongoing compliance, now aided by an electronic system to improve management of compliance information. Assurance is provided bi‐annually to the PQRS Committee. The 2013/14 Internal Audit plan continued to be based around outcomes and the reporting of assurances against the strategic objectives of the Trust to provide a more robust framework for the receipt of assurances with reports including details of associated risks associated with the topic. Internal Audit provided the Committee with regular updates and formal reports on those aspects of the assurance framework included within the audit programme for the year. In May 2014, the Committee received the Head of Audit Opinion relating to the financial year 2013/14. This opinion confirmed that significant assurance could be given that there is a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls may put the achievement of particular objectives at risk. Where weaknesses have been identified, an action plan is in place to address the issue. The Audit Committee reviewed the Annual Governance Statement taking assurance from Internal Audit Reports, the PQRS Committee, the Finance Committee and updates to the risk register. The Committee was not made aware of any particular concerns around governance or breaches of internal control during the year, and as a result of the assurances received, were able to recommend the Annual Governance Statement for the year to the Trust Board. All reports in which Internal Audit reported that they had gained ‘limited assurance’ from their review were considered specifically by the Audit Committee. As a result of these specific reviews, the Committee were able to satisfy themselves that none of the concerns raised were significant in the context of the Annual Governance Statement and its other responsibilities. The Committee annually reviews its Terms of Reference, making minor amendments and clarifications as appropriate. Updated Terms of Reference are attached at Appendix 1. The Committee undertook a self‐assessment of its effectiveness based on the requirements of an Audit Committee as published in the NHS Audit Committee Handbook in September 2013. This was revisited in May 2014 and reported to the Committee.

2.2 Internal Audit The Committee approved the Internal Audit Plan for 2013/14 at its meeting in May 2013. They followed this up with regular reviews of both progress against the 2013/14 audits in the plan and the outcomes of the various reviews carried out, with the Internal Auditors being regular attendees at the meetings to provide these updates. The three year Internal Audit Plan to 2015/16 is already agreed. A full programme of internal audit reviews was undertaken during the year. A total of 55 audits were planned. As at July 2014, 44 had been issued as final reports, 2 were in draft, 1 was deferred (following approval from the Committee) and 8 were nearing completion or were to be completed in early 2014/15. The Committee received the full reports for reviews for which either no assurance or limited assurance had been provided. The Committee were informed of key issues relating to reviews for which significant assurance had been provided and had the opportunity to review the reports in full if they so wished. Individual reports do not contain specific recommendations for action by managers but instead highlight the risks that arise from any gaps in control or non‐compliance with

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controls and it is for management to determine the appropriate actions to address those risks. Draft reports are also shared with the Chair of the Committee and a specific report on outstanding actions i.e. those actions not completed by the agreed target date is also considered at each meeting. This ensures that follow up of agreed actions is monitored by the Committee. The Trust’s Service Level Agreement for internal audit services includes a number of performance indicators which measure Internal Audit’s ability to produce timely reports for management and the performance of management in responding to the issues raised within audit reports. Performance against key indicators is reported at each Audit Committee meeting. Internal Audit presented their Annual Report on 2013/14 at the Committee meeting in July 2014. The Public Sector Internal Audit Standards issued in December 2012 came into effect on 1 April 2013. These standards are in line with best global practice and the International Standards for the Professional Practice of Internal Auditing, and Internal Audit’s satisfactory performance against these standards was detailed in their annual report.

2.3 External Audit Following the outsourcing of the Audit Practice Arm of the Audit Commission in 2012, KPMG were appointed as the Trust’s external auditors for a period of 3 years to July 2015. Representatives of External Audit attend each Audit Committee meeting, and have regular liaison meetings with the Chair of the Committee and the Director of Finance. The purpose of the discussion is to ensure that there are no matters of concern regarding the running of the organisation that should be raised with the Audit Committee. Any matters discussed at these meetings will be reported to the Board of Directors. KPMG provided their plan to the Audit Committee in December 2013. This outlined key audit risks which were reported back to the Committee in the External Auditor’s ISA 260 report. At the meeting in May 2014, the Annual Accounts and Annual Report were reviewed prior to presentation to the Board. External Audit gave an unqualified opinion on the accounts and a clean opinion on the economy, efficiency and effectiveness of the Trust following the receipt of the third party assurances on the Quality Report. Specific risks as highlighted in the plan with regard to the revaluation of land and buildings and provisions were discussed in detail with the Audit Committee and the accounting treatment agreed. The fee for External Audit for work undertaken under the Audit Code included the opinion on the financial statements, the review of the Annual Governance Statement, the opinion on the economy, efficiency and effectiveness of the Trust, work to support the Whole of Government Accounts and the review of the Quality Report and Charitable Funds Audit. The value of this work was £45,405 for 2013/14. KPMG also provided non‐audit services during the year. In particular, KPMG provided services with regard to VAT and pension advice, with a total value of £39,000. Appropriate safeguards were put in place to ensure continued audit objectivity.

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2.4 Local Counter Fraud Service (LCFS) An important function of the LCFS is to ensure that the organisation is being proactive in the prevention of fraud and that any potential frauds that do come to light are dealt with and reported appropriately. The Committee approved the 2013/14 LCFS plan in March 2013 at a level of 80 proactive days. This was the same level as 2012/13. The Local Counter Fraud Specialist is a regular attendee at Committee meetings and provides regular updates on progress against the plan. The main areas of work undertaken during 2013/14 were: Counter fraud pro‐active exercises on the following areas: Taxi services, Purchase cards, Hospital travel costs scheme, Whistleblowing, and Income analysis. Final reports were issued on the first three areas listed above and although no indicators of fraud were identified, some weaknesses in control which if not addressed may have allowed fraud to go undetected. Consequently, management agreed appropriate actions to address these weaknesses. The last two areas related to analysis work to establish if any cases of whistleblowing involved any fraud issues and to identify income sources to ensure that all had been included in the counter fraud pro‐active work plan. There were five referrals of suspected fraud or corruption to the LCFS during the year. These were investigated in line with the Trust’s Fraud and Corruption Policy and all cases were reported to the Committee during the course of the year. An annual report on anti‐fraud work for 2013‐14 was presented to the Audit Committee in July 2014. The Trust’s Fraud Risk Register was updated with advice from LCFS to reflect the changes in likelihood and potential consequence of the fraud risks identified. This did not change significantly the level of risk to the Trust.

2.5 Other Assurance functions A function of the Committee is to review the Losses and Special Payments Register of the Trust on a regular basis, ensuring that payments made under this heading are reasonable, and identifying any particular risks/trends that may become apparent through this particular process. Detailed reports, both written and verbal, were also brought to the Committee on clinical audit, clinical governance and non‐financial topics as the Audit Committee ensures its wider role in assurance across the organisation is fulfilled. In particular the Safecare Annual Audit Plan and Monitoring Report were presented to the Committee as well as Clinical Audit Quarterly Monitoring Reports to monitor compliance with the Trust’s approved process for clinical audit. These reports also provided details of progress in relation to clinical audit activity against the Trust’s Annual Clinical Audit Programme.

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3. Future Plans

The Committee is constantly looking to develop the way that it works and improve the efficiency of the internal control systems across the organisation. In 2014/15 the Committee will continue to take particular cognisance of the challenging level of the efficiency programme required by the Trust due to the change in the economic environment taking assurance from Internal Audit and the Finance Committee. At the end of 2013/14 the Trust implemented a new framework to deliver the efficiency programme through a Transformation Board jointly chaired by the Director of Finance and the Deputy Chief Executive supported by the Associate Director of Strategic Transformation. This went some way to address issues raised in an Internal Audit Report relating to the efficiency programme which gave limited assurance that effective controls and processes were in place to ensure delivery of the Trust’s objectives. The Audit Committee recommended that this report in particular was discussed at the Finance Committee and the recommendations fully explored. This remains a key challenge to the Trust and the Audit Committee will continue to seek assurance as to the operation of the system of assurances relating to the efficiency programme during the year. The Committee will continue to review its Terms of Reference, ensuring compliance with the Code of Governance, and will constantly seek the assurances required of the organisation that the systems of internal control are documented, fit for purpose and complied with consistently. The Committee will continue to invite the Trust Board leads to its meeting on a regular basis to update the Committee on progress towards meeting the Trust wide Corporate Objectives. The Committee will continue to report to the Board of Directors on a regular basis and the Governors through the annual report.

4. Recommendation The Council of Governors is asked to receive the report on behalf of the Audit Committee.

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Appendix 1

GATESHEAD HEALTH NHS FOUNDATION TRUST AUDIT COMMITTEE

TERMS OF REFERENCE

1. Constitution and Purpose The Board hereby resolves to establish a Committee of the Board to be known as the Audit Committee (the Committee). The Committee is a non‐executive committee of the Board and has no executive powers, other than those specifically delegated in these Terms of Reference. The purpose of the Committee is to conclude upon the adequacy and effective operation of the Trust’s overall internal control system including an effective system of integrated governance and risk management. It provides a form of independent check upon the executive arm of the Board. 2. Authority and Relationship with other Committees The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co‐operate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary. The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control. The Committee may also request specific reports from individual functions within the Trust (e.g. clinical audit) as they may be appropriate to the overall arrangements. In addition, the Committee will review the work of other committees within the Trust, whose work can provide relevant assurance to the Audit Committee’s own scope of work. The Committee will wish to satisfy itself on the assurance that can be gained from the Patient Quality Risk and Safety (PQRS), and Human Resources (HR) Committees. The Committee will receive regular updates from the Director of Nursing, Midwifery & Quality on delivery against the governance framework, and an annual report on Risk Management. Members of the Committee also attend PQRS, BSD and HR committees. 3. Duties The Committee is responsible to the Board of Directors for the following main functions: 3.1 Governance, Risk Management and Internal Control The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the Trust’s activities (both clinical and non‐clinical), that supports the achievement of the Trust’s objectives. In particular, the Committee will review the adequacy of:

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• All risk and control related disclosure statements (in particular the Annual Governance Statement), together with any accompanying Head of Internal Audit statement, External Audit opinion or other appropriate independent assurances, prior to endorsement by the Board.

• The underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements as set out in the Trust’s Governance Framework and risk register.

• The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements.

• The policies and procedures for all work related to fraud and corruption as set out in Clause 47 and Schedule 14 of the Terms and Conditions for the Provision of Health Services as required by the Counter Fraud and Security Management Service.

In carrying out this work the Committee will primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness. This will be evidenced through the Committee’s use of an effective Governance Framework to guide its work and that of the audit and assurance functions that report to it. 3.2 Internal Audit The Committee shall ensure that there is an effective Internal Audit function established by management, which meets mandatory Government Internal Audit Standards and provides appropriate independent assurance to the Committee, Chief Executive and Board. This will be achieved by:

• Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal of the Internal Audit Service.

• Review and approval of the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the Trust as identified in the Governance Framework.

• Consideration of the major findings of Internal Audit work (and management’s response), and ensuring co‐ordination between the Internal and External Auditors to optimise audit resources.

• Ensuring that the Internal Audit function is adequately resourced, subject to the processes outlined in the Audit Consortium Constitution, and has appropriate standing within the Trust.

• Annual review of the effectiveness of Internal Audit.

3.3 External Audit The Committee shall review the work and findings of the External Auditor appointed by the Governors and consider the implications and management’s responses to their work. This will be achieved by:

• The Committee will agree with the Council of Governors the criteria for appointing, reappointing and removing auditors. The Audit Committee should make recommendations to the Council of Governors in relation to the appointment, re‐appointment and removal of the External Auditor and approve the remuneration and terms of engagement of the external auditor.

• Consideration of the performance of the External Auditor and reporting at least annually to the Council of Governors on the continued adequacy or otherwise of the appointed auditors, including recommendations for the tendering of External Audit services.

• Discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan, and ensuring co‐ordination, as appropriate, with other External Auditors in the local health economy.

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• Discussion with the External Auditors of their evaluation of audit risks and assessment of the Foundation Trust in line with the tendered audit fee and agreement of any additional work and fees.

• Reviewing all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work undertaken outside of the annual audit plan, together with the appropriateness of the management responses.

• Develop and implement policy on the engagement of the external auditor to supply non‐audit services, taking into account relevant ethical guidance regarding the provision of non‐audit services by the external audit firm.

3.4 Local Counter Fraud Service (LCFS) The Committee shall ensure that there is an effective LCFS function established by management, which meets the Secretary of State’s Directions. This will be achieved by:

• Consideration of the provision of the LCFS function, the cost of the service and any questions of resignation and dismissal of the service, subject to the processes outlined in the Audit Consortium Constitution;

• Review and approval of the LCFS Strategic and Annual Plan; • Consideration of the major findings of LCFS work and fraud investigations (and management’s

response); • Ensuring that the LCFS function is adequately resourced; • Annual review of the effectiveness of the LCFS function.

3.5 Other Assurance Functions

• The Committee shall review the findings of other significant assurance functions, both internal and external to the Trust, and consider the implications to the governance of Trust.

• The Committee shall review arrangements by which staff of the NHS Foundation Trust may raise, in confidence, concerns about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters with reference to the

o Whistleblowing Policy o Bribery Act o Money Laundering Office o Compliance Office.

3.6 Financial Reporting The Committee shall review the Annual Report and Financial Statements before submission to the Board, focusing particularly on:

• The wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the Committee

• Changes in, and compliance with, the accounting policies and practices • Unadjusted mis‐statements in the financial statements • Major judgemental areas • Significant adjustments resulting from the audit

The Committee shall also ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Board.

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3.7 Other Functions The Committee shall review proposed changes to the Standing Orders and Standing Financial Instructions. The Committee shall receive and review the schedules of losses and special payments and authorise the Chief Executive and Director of Finance to sign off the approval to write off these items. 4. Reporting and Accountability Arrangements The minutes of Committee meetings shall be formally recorded and submitted to the Board. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board, or require executive action. The Committee will report to the Board annually on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the Governance Framework, the completeness and embeddedness of risk management in the Trust, the integration of governance arrangements and the appropriateness of the self‐assessment against the Trust’s Quality Standards. The Committee will carry out annual self assessment reviews of its effectiveness and functioning. 5. Other Matters The Committee shall be supported administratively by the Deputy Director of Finance, as audit liaison officer, whose duties in this respect will include:

• Arranging the taking of the minutes and keeping a record of matters arising and issues to be carried forward through appropriate secretarial support

• Advising the Committee on pertinent areas

The Director of Finance will agree the agenda with the Chair and attendees and collation of papers. 6. Membership and Responsibilities Chair & Members Membership will comprise the Non‐Executive Director Chair of the Audit Committee and three other Non‐Executive Directors. Attendees Director of Finance and Information Director of Nursing, Midwifery & Quality A representative of External Audit A representative of Internal Audit A representative of the Local Counter Fraud Service Other Executive Directors and officers will be invited to attend as required to discuss matters of internal control Officers Deputy Director of Finance Nominee of the Trust Board Secretary Quorum The Committee shall be quorate when at least two members are present.

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Frequency of Meetings Meetings shall be held not less than 4 times a year, including at least one meeting a year with both Internal and External Auditors without Executive Director presence. Internal Auditors, External Auditors, or Local Counter Fraud Specialist may request a meeting in exceptional circumstances. Reporting Line The Committee will report to the Board of Directors, and report to the Council of Governors, where there are any matters in respect of which it considers that action or improvement is needed, making recommendations as to the steps to be taken. Minutes Minutes are held by the Nominee of the Trust Board Secretary and are circulated to members and attendees with the agenda for the following meeting.

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