How To Write Off A Trust Account From A Profit To A Profit

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1 EXTRAORDINARY MEETING OF THE BOARD OF DIRECTORS IN PUBLIC AGENDA Date: Friday 24 th May 2013 Time: to 12.00hrs Venue: Board Room, Elizabeth House, Fulbourn, Cambridge Time Item Paper 1 09:30 Welcome 2 Apologies for absence 3 Declarations of Interest To declare any pecuniary or non pecuniary interests 4 09:35 Minutes of the meeting held on 1 May 2013, to be confirmed as an accurate record To follow 5 09:40 Matters Arising 09:45 Questions from members of the public relating to agenda items Governance and Risk 6 09:50 Draft Financial Accounts (to include Letter of Representation) Report of the Interim Director of Finance To note and approve. 7 10:00 Draft Annual Report Report of the Interim Trust Secretary To note and approve Draft Annual Governance Statement Report of the Chief Executive To note and approve Draft Quality Accounts Report of the Director of Nursing To note and approve Attached Attached Attached Attached

2 Strategy Time Item Paper Questions from members of the public relating to Governance and Risk agenda items Draft Annual Plan Report of the Director of Service Improvement. To note. Questions from members of the public relating to Strategy To Follow Other Business/For Information Any Other Business Points of Reflection Date of next meeting The next scheduled meeting of the Board to be held in public on Wednesday 5 June 2013, Board Room, Fulbourn at 9.00am Questions from members of the public relating to Other Business/For Information agenda items CLOSE

3 Agenda Item: 6 BOARD OF DIRECTORS MEETING REPORT Subject: Annual Accounts FY13 Date: 16 May 2013 Author: Deputy Director Corporate Finance Lead Director: Director of Finance Executive Summary: The Trust has delivered an operating surplus of 4.7m and a net surplus of 0.95m consistent with performance reported during the course of the year. The Trust has delivered a Financial Risk Rating of 3 ahead of the planned 2. The accounts have been audited by PriceWaterhouse Coopers and due to the very tight timescales for this work, a copy of their letter of representation will be circulated before the meeting. The accounts and this paper will have been reviewed by the AAC on the 22 nd May 2013 so in advance of this Board meeting and due to timing a verbal update of the AAC discussions/decisions will be provided to the Board by the Chair of AAC and the Director of Finance. Recommendations: The Board is asked to approve the accounts The Board is asked to approve the Chairman and Chief Executive to sign the accounts to evidence the Boards approval The Board is asked to authorise the Director of Finance to sign the Letter of representation. Relevant Strategic Priorities (please mark in bold) Our services will be recognised as world class We will develop service plans that achieve financial stability We will develop our built environment and technology infrastructure to deliver our vision We will deliver care through engaged and empowered people We will develop strong relationships based on trust and mutual respect with key stakeholders Links to BAF/Corporate Risk Register None

4 Details of additional risks associated with this paper (may include CQC Essential standards, NHSLA, NHS Constitution) No additional Risks Financial implications/impact Legal implications/impact Partnership working and public engagement implications/impact Committees/groups where this item has been presented before Has a QIA been completed? If yes provide brief details None None Audit and Assurance Committee Not applicable 1 PURPOSE This report sets out the Trusts audited financial statements for FY13 for the Committee s review and approval. 2 BACKGROUND The Trust is required to complete Statutory Annual Accounts in a format agreed by, and within tight deadlines set by, the Independent Regulator (Monitor). The accounts are presented in Appendix 2 and have been audited by PriceWaterhouseCoopers (whose independent report is presented as a later agenda item). Initial draft accounts for FY13 were submitted to both Monitor and our external auditors on 19 April The approved annual report and accounts are then submitted to Monitor by 30th May 2013 and must be laid before parliament by 26th June 2013, but will be approved by the Trust s Board of Directors at a special meeting on 24 May POSITION The out-turn in these accounts is consistent with figures reported to the Quality and Performance Committee throughout the year. For the benefit of Committee members the following paragraphs explain some of the significant variances from the FY12 accounts; Operating Income from continuing activities has decreased by 3.5m from 135.7m to 132.3m. The major influences on this was that the FY12 figure included 4.2m reversal of impairment for the Cavell Centre and the FY13 includes the profit on disposal of the cobwebs building of 0.8m. Operating Expenditure from continuing activities has decreased by 3.6m from 131.2m to 127.6m. The major variances are identified in Appendix 1. Operating Income and expenditure from discontinuing activities has decreased from 28.3m to 0.9m in the year. This reflects the disposal of the ASP business to Serco which was effective from 13 th April 201.

5 Property plant and equipment has increased from 103.4m to 104.4m which represents the increase in actual capex during the year ( 6.7m) over depreciation ( 3.5m) and disposals ( 1.7m) Current Assets Trade and other receivable have increased from 11.6m to 16.6m. This is due to an increase in accrued income of 6.2m which related to the Adult Social Care contract for FY13 Current liabilities Trade and other payables have increased from 15.7m to 21.2m. This is due to an increase in accrued expenditure of 6.2m which related to the Adult Social Care contract for FY13. Current liabilities Other liabilities have increased from 3.8m to 5.6m. This is due to the deferral of Serco income from the divestment across the next three years as agreed with the auditors Revaluation Reserve has decreased from 21.9m to 20.8m. This is the due to the impairments on Willow and Denbigh ward of 0.5m and the removal of 0.6m of revaluation that related to building disposed of during the year. 4 MATERIAL CHANGES SINCE FIRST DRAFT The only material change on the primary financial statements from the draft accounts presented to the committee in April reflects the need to recalculate the impairment value for the Willow and Denbigh wards as a result of incorrect Gross Internal Area figures being provided to the independent valuers. The amendment increased the impairment on the Statement of Comprehensive income 0.219m, and a corresponding reduction in the revaluation reserve and Property Plant and Equipment. There have been a number of changes between categorisations within the debtors and creditors but nothing which impact on the total value. 5 LETTER OF REPRESENTATION Each year the Trust s Auditors ask the Trust to sign a letter of representation which confirms the management s assumptions and accounting treatments used in the preparation of the accounts. A draft of the letter was reviewed by the Audit and Assurance Committee. 6 CONCLUSION The Board is asked to approve the accounts The Board is asked to approve the Chairman and Chief Executive to sign the accounts to evidence the Boards approval The Board is asked to authorise the Director of Finance to sign the Letter of representation.

6 Appendix 1 - Operating Expenditure from continuing activities 2012/ /12 Movement Net of Per Accounts ASP Net of ASP Per Accounts ASP Net of ASP ASP Comments Purchase of healthcare from non NHS bodies Improved performance on Out of area placements Employee Expenses - Executive Directors Employee Expenses - Non-executive directors Employee Expenses - Staff Reductions to staff costs. Supplies and services - clinical (excluding drug costs) Supplies and services - general (0.0) Establishment (0.1) Research and development (not included in employee expenses) (0.1) Research and development (included in employee expenses) Transport (0.1) Premises Increase/decrease in provision for impairment of receivables (0.0) 0.0 (0.0) Drug costs (non inventory drugs only) Rentals under operating leases - minimum lease receipts Depreciation on property, plant and equipment (0.1) Amortisation on intangible assets No new provisions required in FY13

7 Impairments of property, plant and equipment Audit services- statutory audit (0.0) Other auditors remuneration (0.4) Clinical negligence (0.1) Legal fees (0.1) Consultancy costs (0.6) Training, courses and conferences Patient travel (0.0) Car parking & Security (0.0) Redundancy (0.1) (0.3) Hospitality Insurance Losses, ex gratia & special payments (0.0) Other 13.0 (0.1) (4.7) 10.9 (2.2) TOTAL No I&E impairments in the year Relates to the Quality Governance works Additional costs incurred as part of the turnaround program Implementation of MARS scheme The FY13 figure includes third party contracts of 1.2m which were previously settled by Serco and charged elsewhere in previous years. The FY12 figures was depressed by a number of released contingencies and provisions which were no longer required.

8 Cambridgeshire and Peterborough NHS Foundation Trust Annual Accounts 2012/13

9 FOREWORD TO THE ACCOUNTS These accounts for the period 1 April 2012 to 31 March 2013 have been prepared by CAMBRIDGESHIRE AND PETERBOROUGH NHS FOUNDATION TRUST in accordance with paragraphs 24 and 25 of schedule 7 to the National Health Services Act Date 24th May 2013 Signed :.. Chief Executive

10 Independent Auditors Report to the Council of Governors of Cambridgeshire and Peterborough NHS Foundation Trust

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12 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 MARCH 2013 Continuing Activities Discontinued Activities * Total 2012/13 Continuing Activities Discontinued Activities * Total 2011/12 Note '000 '000 '000 '000 '000 '000 Operating Income , , ,730 28, ,075 Operating Expenses 3.1 (127,636) (957) (128,593) (131,208) (28,345) (159,553) Operating surplus 4,693-4,693 4,522-4,522 Finance Costs Finance income Finance Costs 9 (1,613) - (1,613) (1,599) - (1,599) PDC Dividends payable (2,202) - (2,202) (2,023) - (2,023) Net Finance Costs (3,745) - (3,745) (3,495) - (3,495) Surplus for the year from continuing operations Other comprehensive income ,027-1,027 Impairments (693) - (693) (556) - (556) Revaluations ,341-3,341 TOTAL COMPREHENSIVE INCOME / (EXPENSE) FOR THE YEAR ,812-3,812 * Discontinued activities represent the transactions of the Anglia Support Partnership which was sold to Serco Limited on 13 April Full details can be found in note 37. The notes on pages 5 to 34 form part of these accounts. Page 1

13 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH March March 2012 Note '000 '000 Non-Current assets Intangible assets 11.1& Property, plant and equipment 12.1 & , ,414 Total non-current assets 104, ,466 Inventories Trade and other receivables 17 16,584 11,588 Non-current assets for sale and assets in disposal groups Cash and cash equivalents 18 9,739 8,144 Total current assets 26,395 20,946 Trade and other payables 19.1 (21,186) (15,708) Borrowings 20 (645) (854) Provisions 22.1 (487) (224) Other liabilities - Deferred Income (5,657) (3,760) Total current liabilities (27,975) (20,546) Total assets less current liabilities 102, ,866 Non-current liabilities Borrowings 20 (28,541) (29,613) Provisions 22.1 (1,088) (1,492) Total non-current liabilities (29,629) (31,105) Total assets employed 73,016 72,761 Financed by (taxpayers' equity) Public Dividend Capital 8,658 8,658 Revaluation reserve 25.1& ,608 21,924 Other reserves 33,732 33,732 Income and expenditure reserve 10,018 8,447 Total taxpayers' equity 73,016 72,761 The accounts on pages 1 to 34 were approved by the Board on 24 May 2013 and signed on its behalf by: Signed: Date: 24 May 2013 Chief Executive Page 2

14 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 STATEMENT OF CHANGES IN TAXPAYERS' EQUITY Total Public Dividend Capital Revaluation Reserve Other Reserves Income and Expenditure Reserve '000 '000 '000 '000 '000 Taxpayers' Equity at 1 April ,761 8,658 21,924 33,732 8,447 Surplus for the year Impairments (693) - (693) - - Asset disposals - - (623) Taxpayers' Equity at 31 March ,016 8,658 20,608 33,732 10,018 Taxpayers' Equity at 1 April ,949 8,658 19,139 33,732 7,420 Surplus for the year 1, ,027 Impairments (556) - (556) - - Revaluations - property, plant and equipment 3,341-3, Taxpayers' Equity at 31 March ,761 8,658 21,924 33,732 8,447 Please refer to Notes 1.28 Public Dividend Capital & 1.32 Other reserves for details on the nature of the reserves. The FT's surplus for the year is recognised in the Income and Expenditure Reserve, together with any other gain or loss for the financial year that is not recognised in any other reserve (for example actuarial gains or losses on the Local Government Pension Scheme). The Revaluation Reserve is used to record revaluation gains/losses and impairments/impairment reversals on property plant and equipment (PPE) that are recognised in Other Comprehensive Income. When an asset is sold, or otherwise disposed of, any remaining revaluation reserve balance for the asset is transferred to Retained Earnings. The balance in the reserve is wholly in respect of property, plant and equipment. Page 3

15 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31 MARCH 2013 Cash flows from operating activities Operating surplus from continuing operations 2012/ /12 Note '000 '000 4,693 4,522 Non cash income and expense Depreciation and amortisation 3.1 3,609 4,175 Impairments 3.1-3,614 Reversals of impairments - (4,274) Gain on disposal 2.1 (852) - (Increase)/Decrease in Trade and Other Receivables 17 (4,978) 442 Increase in Inventories (4) (Decrease)/Increase in Trade and Other Payables 19 6,498 (774) (Decrease) / Increase in Other Liabilities 22 1,897 (705) (Decrease)/Increase in Provisions 22.1 (141) 397 Net cash generated from operations 10,882 7,393 Cash flows from investing activities Interest received Purchase of Property, Plant and Equipment (7,628) (8,126) Sales of Property, Plant and Equipment 2,912 - Net cash used in investing activities (4,646) (7,999) Cash flows from financing activities Capital element of finance lease rental payments (35) (223) Capital element of Private Finance Initiative Obligations (670) (607) Interest element of finance lease 9 (60) (65) Interest element of Private Finance Initiative obligations 9 (1,553) (1,534) PDC Dividend paid (2,323) (1,903) Net cash used in financing activities (4,641) (4,332) (Decrease)/Increase in cash and cash equivalents 1,595 (4,938) Cash and Cash equivalents at start of year 18 8,144 13,082 Cash and Cash equivalents at at end of year 18 9,739 8,144 Page 4

16 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS 1 ACCOUNTING POLICIES Monitor has directed that the accounts of NHS foundation trusts shall meet the accounting requirements of the NHS Foundation Trust Annual Reporting Manual (FT ARM) which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the 2012/13 FT ARM issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury s Financial Reporting Manual (FReM) to the extent that they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts. The principal accounting policies adopted in the preparation of these financial statements are set out below. These policies have been consistently applied to all the years presented, unless otherwise stated. Basis of preparation The preparation of financial statements in conformity with IFRSs requires the use of certain critical accounting estimates. It also requires management to exercise its judgement in the process of applying the entity's accounting policies. The areas involving a higher degree of judgement or complexity, or areas where assumptions and estimates are significant to the financial statements, are disclosed in Note 1.4. The directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts 1.1 ACCOUNTING CONVENTION These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities. 1.2 ACQUISITIONS AND DISCONTINUED ACTIVITIES Activities are considered to be acquired whether or not they are taken on from outside the public sector. Activities are considered to be discontinued only if they cease entirely within the Governments Accounting boundary. They are not considered to be discontinued if they transfer from one public sector body to another. 1.3 POOLED BUDGETS The Trust has not entered into any pooled budget arrangements. 1.4 CRITICAL ACCOUNTING JUDGEMENTS AND KEY SOURCES OF 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. 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 CRITICAL JUDGEMENTS IN APPLYING ACCOUNTING POLICIES Holiday pay In accordance with the requirements of IAS 19, the Trust provides for unpaid holiday carried forward by staff at the year end. The Trust has a policy of allowing staff to carry forward only 5 days annual leave at any time. As the Trust does not have centralised holiday records, the estimated provision is based on a sample of 8% of staff at the end of the financial year. This sample has produced an estimated average carry forward of annual leave of 1.43 days KEY SOURCES OF ESTIMATION UNCERTAINTY The following are the key assumptions concerning the future, and other key sources of estimation uncertainty at the end of the reporting period, that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities within the next financial year. The expected useful life of non-current assets has a direct bearing on amortisation and depreciation charges and is currently based on the Trust's best estimate of useful life which is discussed with valuers on an annual basis. Provisions for bad debts are established based on the Trust's understanding of the issues around debt recoverability. Provisions for future pension benefits are calculated on the basis of average lifespans which are subject to fluctuations. Management do not consider that any of these estimates pose a significant risk of material adjustment to the carrying amounts of assets and liabilities within the next financial year. 1.5 INCOME AND EXPENDITURE 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 consideration receivable. 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 the following financial year, that income is deferred. Income from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract. Expenditure on other 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. Page 5

17 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS 1.6 EMPLOYEE BENEFITS SHORT TERM EMPLOYEE BENEFITS Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the accounts to the extent that employees are permitted to carry-forward leave into the following period RETIREMENT BENEFIT COSTS NHS Pension Scheme Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. It is not possible for the NHS foundation trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a defined contribution scheme. Employers pension cost contributions are charged to operating expenses as and when they become due. Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the Trust commits itself to the retirement, regardless of the method of payment. 1.7 TAXATION Corporation Tax The Cambridgeshire and Peterborough NHS Foundation Trust is a Health Service body within the meaning of s 519A ICTA 1988 and accordingly is exempt from taxation in respect of income and capital gains within categories covered by this. There is a power for the Treasury to disapply the exemption in relation to the specified activities of a Foundation Trust (s519a (3) to (8) ICTA 1988). Accordingly the NHS foundation trust is potentially within the scope of Corporation Tax in respect of activities which are not related to, or ancillary to, the provision of healthcare, and where the profits there from exceed 50,000pa. There is no tax liability arising in respect of the current or previous financial year. Other Taxes The Trust accounts for its monthly PAYE and NIC liability as "Other taxes payable" on the Statement of Financial Position. 1.8 PROPERTY PLANT AND EQUIPMENT Recognition Property, plant and equipment is capitalised if: it is held for use in delivering services or for administrative purposes; it is probable that future economic benefits will flow to, or service potential will be supplied to, the Trust; it is expected to be used for more than one financial year; the cost of the item can be measured reliably; and the item has cost of at least 5,000; or collectively, a number of items have a cost of at least 5,000 and individually have a cost of more than 250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives. Valuation 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. Land and buildings used for the Trust s services or for administrative purposes are stated in the Statement of Financial Position at their revalued amounts, being the fair value at the date of revaluation less any subsequent accumulated depreciation and impairment losses. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the Statement of financial position date. In practise the Trust will ensure that there is a full quinquennial valuation and an interim valuation in the third year of each quinquennial cycle. In any intervening year the Trust will carry out a review of movements in appropriate land and building indices and where material fluctuations occur, will engage the services of a professional valuer to determine appropriate adjustments to the valuations of assets to ensure that book values reflect fair values. Fair values are determined as follows: Land and non specialised buildings market value for existing use/modern equivalent asset Specialised building - Depreciated Replacement Cost Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are recognised in operating income. Decreases in asset values and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of other comprehensive income. 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 gave rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised. Other impairments are treated as revaluation losses. Reversals of other impairments are treated as revaluation gains. Page 6

18 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS 1.8 PROPERTY PLANT AND EQUIPMENT (Cont'd) Until 31 March 2008, the depreciated replacement cost of specialised buildings has been estimated for an exact replacement of the asset in its present location. HM Treasury has adopted a standard approach to depreciated replacement cost valuations based on modern equivalent assets and, where it would meet the location requirements of the service being provided, an alternative site can be valued. Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are revalued and depreciation commences when they are brought into use. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation decrease is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the Statement of Comprehensive Income. 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 enterprise and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred. 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.: o management are committed to a plan to sell the asset; o an active programme has begun to find a buyer and complete the sale; o the asset is being actively marketed at a reasonable price; o the sale is expected to be completed within 12 months of the date of classification as Held for Sale ; and o 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 and the assets are not revalued, except where the fair value less costs to sell falls below the carrying amount. Assets are derecognised when all material sale contract conditions have been met. Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as Held for Sale and instead is retained as an operational asset and the asset s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs. 1.9 INTANGIBLE ASSETS Recognition Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the Trust s business or which arise from contractual or other legal rights. They are recognised only when it is probable that future economic benefits will flow to, or service potential be provided to, the Trust; where the cost of the asset can be measured reliably, and where the cost is at least 5,000. Where internally generated assets are held for service potential, this involves a direct contribution to the delivery of services to the public. Intangible assets acquired separately are initially recognised at fair value. Software that is integral to the operating of hardware, for example an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for example application software, is capitalised as an intangible asset. Expenditure on research is not capitalised: it is recognised as an operating expense in the period in which it is incurred. Measurement Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management. The Trust also requires for capitalisation that the intangible asset must be capable of being used in the Trust's activities for more than one year and that it has an identifiable cost of at least 5,000. Subsequently intangible assets are measured at fair value which is considered to approximate to Market Value. Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are recognised in operating income. Decreases in asset values and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of other comprehensive income. Intangible assets held for sale are measured at the lower of their carrying amount or fair value less costs to sell. Page 7

19 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS 1.10 DEPRECIATION AND AMORTISATION Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Freehold land and properties under construction are not depreciated. 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. Property, Plant and Equipment which has been reclassified as Held for Sale ceases to be depreciated upon the reclassification. Assets in the course of construction and residual interests in off-statement of financial position PFI contract assets are not depreciated until the asset is brought into use or reverts to the Trust, respectively. The estimated useful life of an asset is the period over which the Trust expects to obtain economic benefits or service potential from the asset. This is specific to the Trust and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over the lesser of the lease term or their estimated useful lives RESEARCH & DEVELOPMENT EXPENDITURE Expenditure on research is not capitalised: it is recognised as an operating expense in the period in which it is incurred BORROWING COSTS Borrowing costs are recognised as expenses as they are incurred as directed by Monitor DONATED AND GRANT FUNDED ASSETS Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor has imposes a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met. The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment LEASES Finance leases Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS foundation trust, the asset is recorded as Property, Plant and Equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease. The implicit interest rate is that which produces a constant periodic rate of interest on the outstanding liability. The asset and liability are recognised at the inception of the lease, and are de-recognised when the liability is discharged, cancelled or expires. The annual rental is split between the repayment of the liability and a finance cost. The annual finance cost is calculated by applying the implicit interest rate to the outstanding liability and is charged to Finance Costs in the Statement of Comprehensive Income. Operating leases Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease. Leases of land and buildings Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. Leased land is treated as an operating lease. Page 8

20 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS 1.16 PRIVATE FINANCE INITIATIVE (PFI) TRANSACTIONS PFI transactions which meet the IFRIC 12 definition of a service concession, as interpreted in HM Treasury s FReM, are accounted for as on-statement of financial position by the Trust. The underlying assets are recognised as Property, Plant and Equipment at their fair value. An equivalent financial liability is recognised in accordance with IAS 37. The annual contract payments are apportioned between the repayment of the liability, a finance cost and the charges for services. The finance cost is calculated using the effective interest rate for the scheme. The service charge is recognised in operating expenses and the finance cost is charged to Finance Costs in the Statement of Comprehensive Income INVENTORIES Inventories are valued at the lower of cost and net realisable value using the first in first out valuation method. This is considered to be a reasonable approximation to fair value due to the high turnover of stocks. Work-in-progress comprises goods in intermediate stages of production. Partially completed contracts for patient services are not accounted for as work-in-progress CASH AND CASH EQUIVALENTS Cash and bank balances are recorded at the current values of these balances in the NHS Foundation Trust s cash book. These balances exclude monies held in the NHS Foundation Trust s bank account belonging to patients (see Note 35 Third Party Assets below). Account balances are only set off where a formal agreement has been made with the bank to do so. Interest earned and interest charged on bank accounts is recorded as, respectively, finance income and interest expense in the period to which it relates. Bank charges are recorded as operating expenditure in the periods to which they relate. 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. The Trust does not hold any investments with maturity dates exceeding one year from the date of purchase PROVISIONS The NHS Foundation Trust provides for legal or constructive obligations that are of uncertain timing or amount at the Statement of financial position date on the basis of the best estimate of the expenditure required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using HM Treasury s discount rate of 2.2% in real terms, except for early retirement provisions and injury benefit provisions which both use the HM Treasury pension discount rate of 2.35% in real terms. When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably. Present obligations arising under onerous contracts are recognised and measured as a provision. An onerous contract is considered to exist where the Trust has a contract under which the unavoidable costs of meeting the obligations under the contract exceed the economic benefits expected to be received under it 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 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 EU EMISSION TRADING SCHEME EU Emission Trading Scheme allowances are accounted for as government grant funded intangible assets if they are not expected to be realised within twelve months, and otherwise as other current assets. They are valued at open market value. As the NHS body makes emissions, a provision is recognised with an offsetting transfer from the government grant reserve. The provision is settled on surrender of the allowances. The asset, provision and government grant reserve are valued at fair value at the end of the reporting period. Page 9

21 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS 1.23 CONTINGENCIES Contingent assets (that is, assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity s control) are not recognised as assets, but are disclosed where an inflow of economic benefits is probable. Contingent liabilities are not recognised, but are disclosed, 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 FINANCIAL ASSETS AND LIABILITIES Recognition Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items (such as goods and services), which are entered into in accordance with the FT's normal purchase, sale or usage requirements, are recognised when, and to the extent to which, performance occurs, i.e. when receipt or delivery of the goods or services is made. Financial assets and 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 above. All other financial assets and financial 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 The Trust's financial assets are categorised either as loans and receivables or as available-for-sale financial assets. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition. Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. The Trust's loans and receivables comprise - current investments, cash and cash equivalents, NHS receivables, other receivables and accrued income. Loans and receivables are recognised initially at fair value, net of transaction 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 initial fair value of the financial asset (or to its net carrying amount in instances where the effective interest rate is subsequently revised). Interest receivable for the financial year on loans and receivables is calculated by applying the effective interest rate to the opening carrying amount of the asset. The interest receivable is recognised in Finance Income in the Statement of Comprehensive Income. Available-for-sale financial assets The Trust's available-for-sale financial assets comprise equity investments in quoted and unquoted companies. They are included in long-term assets unless the Trust intends to dispose of them within the following financial year. Available-for-sale financial assets are recognised initially at fair value, including transaction costs, and measured subsequently at fair value, with gains or losses recognised in reserves and reported in the Statement of Comprehensive Income as an item of 'other comprehensive income'. When an asset is sold, its cumulative net fair value gain/loss is transferred from reserves and recognised in Finance Costs in the Statement of Comprehensive Income. An equal and opposite reclassification adjustment is also recognised in other comprehensive income. Page 10

22 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS 1.24 FINANCIAL ASSETS AND LIABILITIES (Cont'd) Financial liabilities The Trust's financial liabilities are categorised as "other" financial liabilities at amortised cost. The classification depends on the nature and purpose of the financial liability and is determined at the time of initial recognition. All financial liabilities are recognised initially at fair value, net of transaction costs incurred and 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 initial fair value of the financial liability (or to its net carrying amount in instances where the effective interest rate is subsequently revised). 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 for each financial year is calculated by applying the effective interest rate to the opening carrying amount of the liability. The interest cost is recognised in Finance Costs in the Statement of Comprehensive Income. 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 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 cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset s carrying amount and the present value of the revised future cash flows discounted at the asset s original effective interest rate. The loss is recognised in the Statement of Comprehensive Income and the carrying amount of the asset is reduced through the use of an impairment allowance account. Where an available for sale financial asset has declined in value and there is objective evidence of impairment, the net cumulative loss for the asset that has been recognised in reserves is transferred-out of reserves and recognised in Finance Costs within the Statement of Comprehensive Income. An equal and opposite reclassification adjustment is shown within Other Comprehensive Income VALUE ADDED TAX Most of the activities of the 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 FOREIGN CURRENCIES Transactions 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. At the Statement of financial position date, monetary assets & liabilities denominated in foreign currencies are retranslated at the rates prevailing at the Statement of financial position date THIRD PARTY ASSETS Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the Trust has no beneficial interest in them. Details of third party assets are given in note 35 to the accounts PUBLIC DIVIDEND CAPITAL (PDC) AND PDC DIVIDEND Public dividend capital represents taxpayers equity in the Trust. At any time the Secretary of State can issue new PDC to, and require repayments of PDC from, the Trust. PDC is recorded at the value received. As PDC is issued under legislation rather than under contract, it is not treated as an equity financial instrument. An annual charge, reflecting the cost of capital utilised by the Trust, is payable to the Department of Health as public dividend capital dividend. The charge is calculated at the real rate set by HM Treasury (currently 3.5%) on the average carrying amount of all assets less liabilities, except for donated assets and cash balances with the Government Banking Servicel. The average carrying amount of assets is calculated as a simple average of opening and closing relevant net assets. A note to the accounts discloses the rate that the dividend represents as a percentage of the actual average carrying amount of assets less liabilities in the year. Page 11

23 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS 1.29 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 the Statement of comprehensive income on an accruals basis, including losses which would have been made good through insurance cover had NHS Trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure). The note on losses and special payments is compiled directly from the losses and compensations register. Provisions for future losses are not included SUBSIDIARIES Material entities over which the Trust has the power to exercise control so as to obtain economic or other benefits are classified as subsidiaries and are consolidated. Their income and expenses; gains and losses; assets, liabilities and reserves; and cash flows are consolidated in full into the appropriate financial statement lines. Appropriate adjustments are made on consolidation where the subsidiary s accounting policies are not aligned with the Trust s or where the subsidiary s accounting date is before 1 January or after 30 June. Subsidiaries that are classified as held for sale are measured at the lower of their carrying amount or fair value less costs to sell'. For 2012/13, in accordance with the directed accounting policy from the Secretary of State, the Trust does not consolidate the NHS charitable funds for which it is the corporate trustee ASSOCIATES Material entities over which the Trust has the power to exercise significant influence so as to obtain economic or other benefits are classified as associates and are recognised in the Trust s accounts using the equity method. The investment is recognised initially at cost and is adjusted subsequently to reflect the Trust s share of the entity s profit/loss and other gains/losses. It is also reduced when any distribution is received by the Trust from the entity. Associates that are classified as held for sale are measured at the lower of their carrying amount or fair value less costs to sell OTHER RESERVES Other Reserves within the Statement of Financial Position relate to the difference between the value of fixed assets taken over by the Cambridgeshire and Peterborough Mental Health Partnership NHS Trust at inception on 1 April 2002 and the corresponding value of the Opening Capital Debt. The balance of Other Reserves will remain fixed for the foreseeable future. Page 12

24 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS 1.33 ACCOUNTING STANDARDS THAT HAVE BEEN ISSUED BUT HAVE NOT YET BEEN ADOPTED BY THE TRUST Standards applicable from 2013/14: IAS 1 Presentation of financial statements (amendment). IAS 12 Income Taxes (amendment). IAS 19 (Revised) Employee Benefits IFRS 7 Financial Instruments: Disclosures (amendment) IFRS 13 Fair Value Measurement this standard should be applicable for 2013/14, however, HM Treasury has delayed its adoption by government bodies while it finalises some adaptations. The impact on the financial statements is unknown until these adaptations are finalised. IAS 27 Consolidated and separate financial statements removal of dispensation from consolidating NHS charitable funds Annual Improvements to IFRS This standard is potentially applicable to 2013/14 but has not yet been endorsed by the EU and therefore by HM Treasury policy is not available for NHS bodies to apply. Standards applicable from 2014/15: IFRS 10 Consolidated Financial Statements IFRS 11 Joint Arrangements IFRS 12 Disclosure of Interests in Other Entities IAS 27 Separate Financial Statements (amendment) IAS 28 Investments in Associates and Joint Ventures (amendment) IAS 32 Financial instruments: Presentation (amendment) Other standards in issue: IFRS 9 Financial Instruments this standard will eventually replace IAS 39. It is applicable for periods beginning on or after 1 January 2015, but the standard has not yet been EU endorsed and therefore by HM Treasury policy is not available for NHS bodies to apply. IPSAS 32 - Service Concession Arrangement Page 13

25 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 2.1 ANALYSIS OF INCOME BY CLASSIFICATION 2012/ /12 '000 '000 Income from activities Cost and Volume Contract income 3,848 3,133 Block Contract income 82,838 84,111 Clinical Partnerships providing mandatory services (including S31 agreements) 18,046 18,735 Community Trust - Income from PCT 7,291 6,482 Community Trust - Income not from from PCT Private patient income * (9) 81 Other non-protected clinical income 2,160 2,267 Total income from activities 114, ,867 Other operating income Research and development 5,098 5,356 Education and training 7,050 7,369 Non-patient care services to other bodies 2,301 26,674 Other 3,261 5,508 Profit on disposal of land and buildings Reversal of impairments of property, plant & equipment - 4,274 Rental revenue from operating leases - other Total other operating income 18,590 49,208 Total operating income 133, ,075 * The statutory limitation on private patient income in section 44 of the 2006 Act was repealed with effect from 1 October 2012 by the Health and Social Care Act 2012 Analysis between income from mandatory and non-mandatory services Income from Mandatory Services 104, ,979 Income from Non-Mandatory Services 28,554 58,096 Total operating income 133, ,075 NOTE 2.2 OPERATING LEASE INCOME 2012/ /12 '000 '000 Operating Lease Income Rental revenue from operating leases - other not later than one year; later than one year and not later than five years; TOTAL NOTE 2.3 OPERATING INCOME 2012/ /12 '000 '000 Income from activities by source NHS Foundation Trusts NHS Trusts 2 2 Primary Care Trusts 95,136 94,908 Local Authorities 16,739 17,418 Non NHS: Private patients (9) 81 Non NHS Other 2,140 1,837 Total income from activities 114, ,867 NOTE 2.4 OTHER INCOME 2012/ /12 '000 '000 Analysis of income from activities: Non-NHS Other Other government departments and agencies 1,812 1,837 Other Total 2,140 1,837 Analysis of other operating income: Other Estates recharges - 17 IT recharges Clinical excellence awards Catering 65 1,244 Property rentals Other 2,091 3,370 Total 3,261 5,508 Page 14

26 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 3.1 OPERATING EXPENSES (by type) 2012/ /12 '000 '000 Purchase of healthcare from non NHS bodies 682 1,158 Employee Expenses - Executive Directors Employee Expenses - Non-executive directors Employee Expenses - Staff 87, ,579 Supplies and services - clinical (excluding drug costs) 1,356 1,423 Supplies and services - general 1,043 7,082 Establishment 2,767 4,011 Research and development (not included in employee expenses) Research and development (included in employee expenses) 3,939 - Transport 605 1,944 Premises 6,872 10,108 Increase/decrease in provision for impairment of receivables (31) 604 Drug costs (non inventory drugs only) 1,163 1,601 Rentals under operating leases - minimum lease receipts 1,177 1,395 Depreciation on property, plant and equipment 3,557 4,109 Amortisation on intangible assets Impairments of property, plant and equipment - 3,614 Audit services- statutory audit Other auditors remuneration Clinical negligence Legal fees Consultancy costs Training, courses and conferences Patient travel Car parking & Security Redundancy Hospitality Insurance Losses, ex gratia & special payments 4 3 Other 12,978 6,220 TOTAL 128, ,625 NOTE 3.2 LIMITATION ON AUDITORS LIABILITY The engagement letter states that the liability of Pricewaterhouse Coopers LLP (PwC), its members, partners and staff (whether contract, negligence or otherwise) in respect of services provided in connection with or arising out of the audit shall in no circumstances exceed 1 million in the aggregate in respect of all such services. Page 15

27 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 4.1 EMPLOYEE EXPENSES 2012/ /12 Total Permanent Other Total '000 '000 '000 '000 Salaries and wages 74,673 70,798 3,875 91,810 Social security costs 5,449 5, ,421 Pension costs - defined contribution plans Employers contributions to NHS Pensions 8,610 8,610-10,387 Pension costs - Other contributions Termination benefits Agency/contract staff 3,364-3,364 4,216 Total Gross Staff costs Less Costs capitalised as part of assets 92,937 85,427 7, , Total Employee benefits excl capitalised costs 92,621 85,111 7, ,678 Directors remuneration (which is included in the figures above) is detailed in note 27 of the accounts. NOTE 4.2 EXIT PACKAGES During the financial year, the trust has made a number of staff redundant as a result of service transformation. Details of the termination costs of those redundancies are analysed below : 2012/2013 Exit package cost band Number of compulsory redundancies Cost of compulsory redundancies Number of other departures agreed Cost of other departures agreed Total number of exit packages Total cost of exit packages '000 '000 '000 < 10, ,000-25, ,001-50, , , , , Total Number of exit Packages by Type Exit package cost band Number of compulsory redundancies Cost of compulsory redundancies 2011/2012 Number of other departures agreed Cost of other departures agreed Total number of exit packages Total cost of exit packages '000 '000 '000 < 10, ,000-25, Total Number of exit Packages by Type NOTE 4.3 AVERAGE NUMBER OF EMPLOYEE (WTE BASIS) 2012/ /12 Total Permanent Other Total Number Number Number Number Medical and dental Administration and estates Healthcare assistants and other support staff Nursing, midwifery and health visiting staff Scientific, therapeutic and technical staff Social care staff Bank and agency staff TOTAL 2,283 2, ,925 of which number of Employees (WTE) engaged on capital projects The average number of employees includes the Trust Directors who are on service contracts. NOTE 4.5 EMPLOYEE BENEFITS There was 140,000 (2011/12: 175,563) employee benefits paid during the 12 month period. Page 16

28 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 4.5 EARLY RETIREMENTS DUE TO ILL HEALTH During 2012/13 there were 8 (2011/12: 3) early retirements from the NHS Trust agreed on the grounds of ill-health. The estimated additional pension liabilities of these ill-health retirements will be 559,859 (2011/12: 401,196). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division. NOTE 4.6 NHS PENSION SCHEME Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. 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. The scheme is subject to a full actuarial valuation every four years (until 2004, every five years) and an accounting valuation every year. An outline of these follows: a) 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 to be paid by employers and scheme members. The last such valuation, which determined current contribution rates was undertaken as at 31 March 2004 and covered the period from 1 April 1999 to that date. The conclusion from the 2004 valuation was that the scheme had accumulated a notional deficit of 3.3 billion against the notional assets as at 31 March However, after taking into account the changes in the benefit and contribution structure effective from 1 April 2008, the scheme actuary reported that employer contributions could continue at the existing rate of 14% of pensionable pay. On advice from the scheme actuary, scheme contributions may be varied from time to time to reflect changes in the scheme s liabilities. Up to 31 March 2008, the vast majority of employees paid contributions at the rate of 6% of pensionable pay. From 1 April 2008, employees contributions are on a tiered scale from 5% up to 8.5% of their pensionable pay depending on total earnings. b) Accounting valuation A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period by updating the results of the full actuarial valuation. Between the full actuarial valuations at a two-year midpoint, a full and detailed member data-set is provided to the scheme actuary. At this point the assumptions regarding the composition of the scheme membership are updated to allow the scheme liability to be valued. The valuation of the scheme liability as at 31 March 2008, is based on detailed membership data as at 31 March 2006 (the latest midpoint) updated to 31 March 2008 with summary global member and accounting data. 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) Resource Account, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office. c) Scheme provisions The scheme is a final salary scheme. Annual pensions are normally based on 1/80th of the best of the last 3 years pensionable pay for each year of service. A lump sum normally equivalent to 3 years pension is payable on retirement. Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act Up to and including 2009/10, that increase was based on retail price index, subsequently it is based on the consumer price index. On death, a pension of 50% of the member s pension is normally payable to the surviving spouse. 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, less pension already paid, subject to a maximum amount equal to twice the member s final year s pensionable pay less their retirement lump sum for those who die after retirement, is payable. Page 17

29 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 5.1 OPERATING LEASE 2012/ /12 '000 '000 Minimum lease payments 1,177 1,395 NOTE 5.2 Arrangements containing an operating lease 2012/ /12 '000 '000 Future minimum lease payments due: - not later than one year; 804 1,288 - later than one year and not later than five years; 878 1,354 - later than five years. 1,833 1,607 TOTAL 3,515 4,249 NOTE 5.3 THE LATE PAYMENT OF COMMERCIAL DEBTS (INTEREST) ACT 1998 There were no amounts included within other interest payable arising from claims made under this legislation or Compensation paid to cover debt recovery costs under this legislation NOTE 5.4 AUDITORS' REMUNERATION FOR NON AUDIT SERVICES 2012/ /12 '000 '000 All other non-audit services PWC offered support and advice for the Trust as part of the Trust's efforts to remove itself from significant breach of the terms of the authorisation with the regulator. NOTE 6 DISCONTINUED OPERATIONS On 13 April 2012, the Trust transferred the staff and the activities of Anglia Support Partnership to Serco Limited. Details of the transaction can be found in note 37. NOTE 7 CORPORATION TAX The Trust did not pay any corporation tax in 2012/13 or 2011/12. NOTE 8 FINANCE INCOME 2012/ /12 '000 '000 Interest on bank accounts NOTE 9 FINANCE COSTS - INTEREST EXPENSE 2012/ /12 '000 '000 Finance leases Finance Costs in PFI obligations Main Finance Costs 1,289 1,310 Contingent Finance Costs TOTAL 1,613 1,599 NOTE 10 IMPAIRMENT OF ASSETS 2012/ /12 '000 '000 Abandonment of assets in course of construction - 2,763 Unforeseen obsolescence - 58 Changes in market price 693 1,349 Reversal of impairments - (4,274) Total Net impairment 693 (104) The above impairment figure is split in the above notes as : Operating income (note 2.4) - (4,274) Operating expenditure (note 3.1) - 3,614 Statement of changes in taxpayers equity (104) See Note 12.6 for details of all asset impairments. Page 18

30 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 11.1 INTANGIBLE ASSETS 2012/13 ' /12 '000 Software licences (purchased) '000 Software licences (purchased) '000 Valuation/Gross Cost at 1 April Transferred to disposal group as asset held for sale - (202) Gross costs at 31 March Accumlated amortisation at 1 April Provided during the year Transferred to disposal group as asset held for sale - (185) Accumlated amortisation at 31 March Net book value 2012/ /12 '000 '000 NBV - Purchased at 31 March - 52 NOTE 11.2 ECONOMIC LIFE OF INTANGIBLE ASSETS Min Life Max Life Years Years Intangible assets - internally generated Software - 5 Page 19

31 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 12.1 PROPERTY PLANT AND EQUIPMENT 2012/13 Total Land Buildings excluding dwellings Assets under Construction & POA Plant & Machinery Transport Equipment Information Technology Furniture & Fittings '000 '000 '000 '000 '000 '000 '000 '000 Cost or Valuation at 1 April ,358 18,072 97,518 8,059 1, ,643 2,518 Additions - purchased 6,723-2,357 3, Additions - leased Impairments (693) - (693) Reclassifications - - 3,609 (3,944) Disposals (4,735) (400) (1,674) (30) 12 (173) (2,321) (149) Cost or valuation at 31 March ,660 17, ,124 7,776 1, ,122 2,552 Accumulated depreciation at 1 April ,944-20,855 2,763 1, ,181 1,756 Provided during the year 3,557-2, Disposals (3,066) - (580) - 9 (173) (2,173) (149) Accumulated depreciation at 31 March ,435-22,988 2,763 1, ,656 1,747 Net book value 31 March 2013 Owned 71,773 17,672 45,684 5, , Finance Lease 3,357-3, On Statement of Financial Position PFI contracts and other service concession 27,913-27, Donated 1,182-1, NBV Total 31 March ,225 17,672 78,136 5, , NOTE 12.2 ANALYSIS OF PROPERTY, PLANT AND EQUIPMENT 31 MARCH 2013 Total Land Buildings excluding dwellings Assets under Construction & POA Plant & Machinery Transport Equipment Information Technology Furniture & Fittings '000 '000 '000 '000 '000 '000 '000 '000 Net book value Protected assets 29,703 6,678 23, Unprotected assets 74,522 10,994 55,111 5, , Total 104,225 17,672 78,136 5, , There has been no disposal of protected assets in 2012/13. Page 20

32 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 12.3 PROPERTY PLANT AND EQUIPMENT 2011/12 Total Land Buildings excluding dwellings Assets under Construction & POA Plant & Machinery Transport Equipment Information Technology Furniture & Fittings '000 '000 '000 '000 '000 '000 '000 '000 Cost or Valuation at 1 April ,026 16,936 93,200 4,320 1, ,080 2,670 Additions - purchased 8,126-1,707 5, Impairments (556) - (556) Reclassifications - - 1,045 (1,475) Revaluations 3,341 1,136 2, Transfered to disposal group as asset held for sale (2,579) - (83) (192) (392) (36) (1,647) (229) Cost or valuation at 31 March ,358 18,072 97,518 8,059 1, ,643 2,518 Accumulated depreciation at 1 April ,105-21,341-1, ,412 1,824 Provided during the year 4,109-3, Impairments 3, , Reversal of impairments (4,274) - (4,274) Transferred to disposal group as held for sale (1,610) - (34) - (241) (31) (1,089) (215) Accumulated depreciation at 31 March ,944-20,855 2,763 1, ,181 1,756 Net book value 31 March 2012 Owned 69,740 18,072 42,994 5, , Finance Lease 3,994-3, On Statement of Financial Position PFI contracts and other service concession 28,454-28, Donated 1,226-1, NBV Total 31 March ,414 18,072 76,663 5, , NOTE 12.4 ANALYSIS OF PROPERTY, PLANT AND EQUIPMENT 31 MARCH 2012 Total Land Buildings excluding dwellings Assets under Construction & POA Plant & Machinery Transport Equipment Information Technology Furniture & Fittings '000 '000 '000 '000 '000 '000 '000 '000 Net book value Protected assets 29,541 6,678 22, Unprotected assets 73,873 11,394 53,800 5, , Total 103,414 18,072 76,663 5, , There were no disposal of protected assets in 2011/12. NOTE 12.5 NBV OF PROPERTY, PLANT AND EQUIPMENT IN THE REVALUATION RESERVE AS AT 31 MARCH 2013 Total Land Buildings excluding dwellings Assets under Construction & POA Plant & Machinery Transport Equipment Information Technology Furniture & Fittings '000 '000 '000 '000 '000 '000 '000 '000 as at 1 April ,924 5,268 16, movement in year (1,316) (219) (1,082) - (3) - - (12) as at 31 March ,608 5,049 15, Page 21

33 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 12.5 PROPERTY, PLANT AND EQUIPMENT (Cont'd) All the freehold and leasehold properties owned by the Foundation Trust were valued by Boshier & Company Chartered Surveyors in the 2011/12 financial year as part of an interim valuation in the third year of five year valuation cycle. The properties were valued as at 31 March 2012 Two buildings on the Fulbourn site were valued in the 2012/13 year namely the Denbigh and Willow wards. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the Statement of financial position date. In practise the Trust will ensure that there is a full quinquennial valuation and an interim valuation in the third year of each quinquennial cycle. In any intervening year the Trust will carry out a review of movements in appropriate land and building indices and where material fluctuations occur, will engage the services of a professional valuer to determine appropriate adjustments to the valuations of assets to ensure that book values reflect fair values. Fair values are determined as follows: Land and non specialised buildings market value for existing use/modern equivalent asset Specialised building - Depreciated Replacement Cost The valuations were in accordance with the requirements of the RICS valuation standards sixth edition and the international valuation standards. The valuation of each property was on the basis of market value, subject to the following assumptions i) For owner occupied property: that the property would be sold as part of the continuing enterprise in occupation; ii) For investment property: that the property would be sold subject to any existing leases; iii) For surplus property and property held for development: that the property would be sold with vacant possession in its existing condition; The Valuer's opinion of market value was primarily derived using: iv) Comparable recent market transactions on arm's length terms; v) The depreciated replacement cost method of valuation as the specialised nature of the asset means that there is no market transactions of this type of asset except as part of the enterprise in occupation and is subject to the prospect and viability of the continued occupation and use. Plant and equipment that have not been revalued are shown at their depreciated value. NOTE 12.6 IMPAIRMENTS The valuations of the Denbigh and Willow wards after building work was completed on the buildings resulted in an impairment of 693,000 in the year. The impairments were charged to the revaluation reserve. Min Life Max Life NOTE 12.7 ECONOMIC LIFE OF PROPERTY, PLANT AND EQUIPMENT Years Years Land - - Buildings excluding dwellings 2 57 Assets under Construction - - Plant & Machinery 5 10 Transport Equipment 5 10 Information Technology 5 10 Furniture & Fittings 5 10 Page 22

34 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 13 & 14 INVESTMENTS The Trust did not hold any investments on the 31 March 2013 (31 March 2012: nil). NOTE 15 NON-CURRENT ASSETS FOR SALE AND ASSETS IN DISPOSAL GROUPS 2012/ /12 '000 '000 NBV of non-current assets for sale and assets in disposal groups at 1 April Plus assets classified as available for sale in the year Less assets sold in year (986) - NBV of non-current assets for sale and assets in disposal groups at 31 March Page 23

35 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 16.1 INVENTORIES 2012/ /12 '000 '000 Drugs Consumables Energy - 17 Other Materials NOTE 17 TRADE AND OTHER RECEIVABLES 2012/ /12 '000 '000 Current NHS Receivables - Revenue 4,982 4,729 Other receivables with related parties - Revenue 1,775 1,462 Provision for Impaired Receivables (420) (636) Prepayments (Non-PFI) 982 2,035 Accrued income 8,243 2,245 PDC dividend receivable 18 - VAT Receivables Other receivables 920 1,283 TOTAL CURRENT TRADE AND OTHER RECEIVABLES 16,584 11,588 Non-Current The Trust has no non-current trade receivables and other receivables. NOTE 17.1 PROVISION FOR IMPAIRMENT OF RECEIVABLES 2012/ /12 '000 '000 At 1 April (Decrease)/Increase in provision (31) 604 Amounts utilised (185) (432) At 31 March NOTE 17.2 ANALYSIS OF IMPAIRED RECEIVABLES 2012/ /12 '000 '000 Ageing of impaired receivables 0 to 30 days to 60 days to 90 days to 180 Days 10 - Over 180 days Total Ageing of non-impaired receivables past their due date 30 to 60 days 1,507 1, to 90 days (234) to 180 Days Over 180 days Total 2,839 3,124 Page 24

36 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 18 CASH AND CASH EQUIVALENTS 2012/ /12 '000 '000 At 1 April 8,144 13,082 Net change in year 1,595 (4,938) At 31 March 9,739 8,144 Broken down into: Cash at commercial banks and in hand Cash with the Government Banking Service 9,722 8,096 Cash and cash equivalents as in SoFP 9,739 8,144 Third party assets held by the NHS Foundation Trust Details of Third Party Assets held by the Trust are detailed in note 35. NOTE 19.1 TRADE AND OTHER PAYABLES 2012/ /12 '000 '000 Current NHS payables - Revenue 2,115 2,163 Amounts due to other related parties - revenue 7, Other Trade payables - capital 386 1,284 Other Trade payables - revenue 1, Other taxes payable 1,785 2,229 Other payables 2,260 2,477 Accruals 5,908 6,618 PDC dividend payable TOTAL CURRENT TRADE AND OTHER PAYABLES 21,186 15,708 There are no non-current trade and other payables. NOTE OUTSTANDING PENSION CONTRIBUTIONS INCLUDED IN NHS PAYABLES ABOVE The outstanding pension contributions included in other payables above 1,101,380 (2011/12: 1,300,280). Page 25

37 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 20 BORROWINGS 2012/ /12 '000 '000 Current Obligations under finance leases Obligations under Private Finance Initiative contracts TOTAL CURRENT BORROWINGS Non-current Obligations under finance leases Obligations under Private Finance Initiative contracts 28,273 28,943 TOTAL NON CURRENT BORROWINGS 28,541 29,613 NOTE 21 PRUDENTIAL BORROWING LIMIT Long term borrowing limit set by Monitor as at 1 April (per Schedule 5 of ToA) 42,400 42,400 Net change in long term borrowing limit agreed by Monitor in year - - Long term borrowing limit set by Monitor as at 31 Dec (per Schedule 5 of ToA) 42,400 42,400 Working Capital Facilty limit set by Monitor as at 1 April (per Schedule 5 of ToA) 10,300 10,300 Net change in working capital factility limit agreed by Monitor in year - - Working Capital Factilty limit set by Monitor as at 31 Dec (per Schedule 5 of ToA) 10,300 10,300 Actual (contracted) working capital facility TOTAL PRUDENTIAL BORROWING LIMIT 52,700 52,700 Long term borrowing at 1 April 30,467 31,297 Net actual borrowing/(repayment) in year - long term (1,281) (830) Long term borrowing at 31 March 29,186 30,467 The NHS Foundation Trust is required to comply and remain within a prudential borrowing limit. This is made up of two elements : - the maximum cumulative amount of long-term borrowing. This is set by reference to the four ratio test set out in Monitor's Prudential Borrowing Code. The financial risk rating set under Monitor's Compliance Framework determines one of the ratios and therefore can impact on the long term borrowing limit. - the amount of any working capital facility approved by Monitor. The Trust's position at 31 March 2013 against the ratios specified by Monitor was as follows: Financial ratios Actual ratios Approved Approved PBL ratios Actual ratios PBL ratios 2012/ / / /12 Minimum dividend cover 3.0x >1x 5.3x >1x Minimum interest cover 5.1x >3x 7.7x >3x Minimum debt service cover 3.6x >2x 5.1x >2x Maximum debt service to revenue 1.7% <3% 1.5% <3% Further information on the NHS Foundation Trust Prudential Borrowing Code and Compliance Framework can be found on the website of Monitor, the Independent Regulator of Foundation Trusts. Page 26

38 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS Current Non-current NOTE 22.1 PROVISIONS FOR LIABILITIES AND CHARGES 31 March March March March 2012 '000 '000 '000 '000 Pensions relating to other staff Other legal claims Agenda for Change Other ,037 Total ,088 1,492 NOTE 22.2 PROVISIONS FOR LIABILITIES AND CHARGES ANALYSIS Pensions - other Other legal Agenda for Total staff claims Change Other '000 '000 '000 '000 '000 At 1 April 2012, as restated 1, ,122 Arising during the year Utilised during the year - Accruals (28) (17) - - (11) Utilised during the year - Cash (676) (53) (12) - (611) At 31 March , Expected timing of cashflows: - not later than one year; later than one year and not later than five years; later than five years TOTAL 1, There are no provisions for pensions to former directors. Pension - Other staff - This reflects the liabilities arising from early retirements and staff who have transferred into the Trust. Other Legal claims - This reflects potential claims against the NHSLA scheme and provision for employer tribunal costs. Agenda for change - This reflects provisions in respect of potential equal pay claims resulting from the introduction of agenda for change. Other - reflects provisions arising from injury benefit claims and dilapidations for Trust properties. NOTE 22.3 CLINICAL NEGLIGENCE LIABILITIES The amount included in provisions of the NHSLA at 31 March 2013 in respect of clinical negligence liabilities of Cambridgeshire and Peterborough NHS Foundation Trust is 677,597 (11/12 : 681,000). NOTE 23 CONTINGENT (LIABILITIES) / ASSETS There were no contingent assets or liabilities arising at the end of the year (2011/12 nil). Page 27

39 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 24 REVALUATION RESERVE 2012/13 Revaluation reserve - property plant and equipment '000 Revaluation reserve at 1 April ,924 Impairments (693) Asset disposals (623) Revaluation reserve at 31 March ,608 NOTE 25 REVALUATION RESERVE 2011/12 Revaluation reserve - property plant and equipment '000 Revaluation reserve at 1 April ,139 Impairments (556) Revaluations 3,341 Revaluation reserve at 31 March ,924 Page 28

40 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 26 RELATED PARTY TRANSACTIONS (Cont'd) The Department of Health is also regarded as a related party. During the year, the Trust has had a significant number of material transactions over 1,000,000 with the Department, and with other entities for which the Department is regarded as the parent Department. These entities are listed below: Strategic Health Authorities Payments to Related Party Receipts from Related Party Amounts owed to Related Party Amounts due from Related Party '000 '000 '000 '000 East of England Strategic Health Authority - 8,219-1,914 Primary Care Trusts Bedfordshire PCT Cambridgeshire PCT 8 50, Mid Essex PCT - 2, West Essex PCT Norfolk PCT - 1, Peterborough PCT 1,536 28, Suffolk PCT NHS Trusts East of England Specialist Commissioning Group - 9, Cambridgeshire Community Services NHS Trust Whipps Cross University Hospital NHS Trust NHS Foundation Trusts Cambridge University Hospitals NHS Foundation Trust 341 1, North Essex Parnership NHS Trust Peterborough and Stamford Hospitals NHS Foundation Trust 1, NHS Pensions Scheme In addition, the Trust has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with Cambridgeshire County Council and Peterborough City Council. The Trust has also received revenue and capital payments from charitable funds, for which the Trust is Corporate trustee. The audited accounts of the Funds Held on Trust are available on request from the Trust's Company Secretary. NOTE 27 MANAGEMENT COMPENSATION Year ending 31 March 2013 Year ending 31 March 2012 Short term employee benefits Post employment benefits Short term employee benefits Post employment benefits Dr Attila Vegh (Chief Executive) 225,209 27,951 83,311 10,340 Ms Jenny Raine (Chief Executive (acting)) ,075 13,004 Dr Chess Denman (Medical Director) 165,006 20,479 41,252 5,120 Dr Tom Denning (Medical Director) ,953 13,775 Mr Tim Bryson (Director of Nursing and Quality) ,195 12,362 Mrs A Newton (Director of Operations) ,344 16,579 Barbera McLean (Chief Operating Officer) Note 1 64,484 8,003 25,949 3,221 Mr Keith Spencer (Director of People and Business Development) 151,827 18, ,410 17,444 Ms Jenny Raine (Director of Finance and Performance) Note 2 14,019 1,740 66,271 8,225 Mr D McNally (Director of Finance and Performance (Acting)) Note 3 20,700 2,569 67,919 8,430 Anne Campbell (Non - Executive Chairman) Note 4 23,060-56,155 - David Edwards (Non - Executive Chairman) Note 5 36, Lucy O'Brien (Non - Executive Director) Note 6 4,138-16,551 - Ashish Dasgupta (Non - Executive Director) 20,098-20,098 - Terry Holloway (Non - Executive Director) - Note 7 16,624-16,551 - Robert Dixon (Non - Executive Director) 16,550-16,551 - Howard Nelson (Non - Executive Director) - - 8,276 - Rebecca Stephens (Non - Executive Director) ,793 - Ian Goodyer (Non - Executive Director) Note 8 12,413-16,551 - Tom Abell (Chief Information Officer and Director of Service Improvement) Note 9 107,137 13, Melanie Coombes (Director of Nursing) Note 10 43,460 5, Darren Cattell (Interim Director of Finance) Note , Mick Simpson (Chief Operating Officer) Note ,407 12, Totals 1,173, ,740 1,066, ,499 There were no long term benefits, termination benefits or share based payments made in the year. Short term benefits includes social security contributions, which encompass employers national insurance contributions. Note 1 - Resigned April 2012 Note 7 - End of term of office March 2013 Note 2 - Resigned April 2012 Note 8 - End of term of office December 2012 Note 3 - Acted up May to June 2012 Note 9 - Apointed April 2012 Note 4 - Resigned August 2012 Note 10 - Appointed November 2012 Note 5 - Appointed September 2012 Note 11 - Appointed July 2012 under a contract for services Note 6 - End of term of office June 2012 Note 12 - Appointed April 2012 Page 29.

41 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 28 CONTRACTUAL CAPITAL COMMITMENTS 2012/ /12 '000 '000 Property, Plant and Equipment NOTE 29 FINANCE LEASE OBLIGATIONS 2012/ /12 '000 '000 Gross lease liabilities of which liabilities are due 888 1,624 - not later than one year; later than one year and not later than five years; later than five years Finance charges allocated to future periods (611) (736) Net lease liabilities not later than one year; later than one year and not later than five years; later than five years NOTE 30.1 PFI OBLIGATIONS (ON SOFP) 2012/ /12 '000 '000 Gross PFI liabilities 51,061 54,583 of which liabilities are due - not later than one year; 1,919 1,959 - later than one year and not later than five years; 7,502 7,585 - later than five years. 41,640 45,039 Finance charges allocated to future periods (22,152) (25,004) Net PFI liabilities 28,909 29,579 - not later than one year; later than one year and not later than five years; 2,763 2,585 - later than five years. 25,487 26,358 The Trust is committed to make the following payments for on-sofp PFI obligations during the next year in which the commitment expires in the 31st to 35th years (inclusive) 3,840,000 (2011/12 3,702,000). The Trust has no off - SoFP PFI schemes. NOTE 30.2 PFI OBLIGATIONS (SERVICE CHARGE COMMITMENTS) 2012/ /12 '000 '000 Future service charge commitments due: - not later than one year; 1,630 1,572 - later than one year and not later than five years; 6,938 6,689 - later than five years. 61,604 60,629 TOTAL 70,172 68,890 The Trust is committed to make payments in relation to service charges on its PFI scheme. The charges are subject to an index linked inflation adjustment each year. On 19 th June 2007 the Trust concluded contracts under the Private Finance Initiative (PFI) with Peterborough (Progress Health) PLC for the construction of a new 102 bed hospital and the provision of hospital related services. The PFI scheme was approved by the NHS Executive and HM Treasury as being better value for money than the public sector comparator. Under IFRIC 12, the PFI scheme is deemed to be on statement of Financial Position, meaning that the hospital is treated as an asset of the Trust, being acquired through a finance lease. The payments to Progress Health in respect of the facility (Cavell Centre) have therefore been analysed into finance lease charges and service charges. The accounting treatment of the PFI scheme is detailed in the accounting policies note. The service element of the contract was 1,616,000 (2011/12: 1,562,000). The Cavell Centre was handed over to the Trust in two phases in November 2008 and May Payments under the scheme commenced in November The agreement is due to end in November The estimated value of the scheme at inception was 25,700,000. Page 30.

42 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 32.1 FINANCIAL ASSETS BY CATEGORY Loans and receivables '000 Assets as per SoFP NHS Trade and other receivables excluding non financial assets (at 31 March 2013) 4,982 Non-NHS Trade and other receivables excluding non financial assets (at 31 March 2013) 2,359 Cash and cash equivalents at bank and in hand (at 31 March 2013) 9,739 Total at 31 March ,080 NHS Trade and other receivables excluding non financial assets (at 31 March 2012) 4,729 Non-NHS Trade and other receivables excluding non financial assets (at 31 March 2012) 2,579 Cash and cash equivalents (at bank and in hand (at 31 March 2012) 8,144 Total at 31 March ,452 NOTE 32.2 FINANCIAL LIABILITIES BY CATEGORY Other financial liabilities at amortised cost '000 Liabilities as per SoFP Obligations under finance leases (at 31 March 2013) 277 Obligations under Private Finance Initiative contracts (at 31 March 2013) 28,909 NHS Trade and other payables excluding non financial assets (at 31 March 2013) 2,115 Non-NHS Trade and other payables excluding non financial assets (at 31 March 2013) 19,071 Provisions under contract (at 31 March 2013) 1,575 Total at 31 March ,947 Obligations under finance leases (31 March 2012) 888 Obligations under Private Finance Initiative contracts (31 March 2012) 29,579 NHS Trade and other payables excluding non financial assets (31 March 2012) 2,163 Non-NHS Trade and other payables excluding non financial assets (31 March 2012) 13,545 Provisions under contract (at 31 March 2012) 1,716 Total at 31 March ,891 Financial Risk management Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the Trust has with primary care trusts and the way those primary care trusts are financed, the Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. Financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the Trust in undertaking its activities. Market Risk Market risk is the possibility that financial loss might arise as a result of changes in such measures as interest rates and stock market movements. A significant proportion of the Trust's transactions are undertaken in sterling and so its exposure to foreign exchange risk is minimal. It holds no significant investments other than short-term bank deposits. Other than cash balances, the Trust's financial assets and liabilities carry nil or fixed rates of interest and the Trust's income and operating cashflows are substantially independent of changes in market interest rates. Page 31.

43 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 32.2 FINANCIAL LIABILITIES BY CATEGORY (cont) Credit Risk Credit risk is the possibility that other parties might fail to pay amounts due to the Trust. Credit risk arises from deposits with banks and financial institutions as well as credit exposures to the Trust's commissioners and other debtors. Surplus operating cash is only invested with banks and financial institutions that are rated independently with a minimum score of A1 (Standard and Poor's), P-1 (Moody's) or F1 (Fitch). The Trust's net operating costs are incurred largely under annual service agreements with local primary care trusts, which are financed from resources voted annually by Parliament. As primary care trusts are funded by government to buy NHS patient care sevices, no credit scoring of these is considered necessary. An analysis of the ageing of receivables and provision for impairments can be found at note 7.2 'Trade and other receivables'. Liquidity risk Liquidity risk is the possibility that the Trust might not have funds available to meet its commitments to make payments. Prudent liquidity risk management includes maintaining sufficient cash and the availability of funding from an adequate amount of committed credit facilities. NHS foundation trusts are required to comply with the Prudential Borrowing Code made by Monitor, the Independent Regulator of Foundation Trusts, and further details of the Trust's compliance can be found at note 21 'Prudential Borrowing Limit'. NOTE 33 LOSSES AND SPECIAL PAYMENTS There were 20 cases of losses and special payments (2011/12: 19 cases) totalling 4,000 (2010/11: 3,474) paid during 2012/13. Page 32.

44 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 34 OPERATING SEGMENTS IFRS 8, Operating Segments ; replaces IAS 14, Segment Reporting and requires a management approach, under which segment information is presented on the same basis as that used for internal reporting purposes by the Chief Operating Decisionmaker. The operating segments to be disclosed in these accounts are therefore identified on the basis of internal reports regularly reviewed by the Board of Directors, the Board of Directors being considered to be the chief operating decision-maker for the Trust, in order to allocate resources to the segments and to assess their respective performance. The Board considers the Trust from a service perspective, organised into two business segments; Healthcare; and Anglia Support Partnership. The internal divisions of the healthcare reportable segment (Adults Mental Health, Child and Adolescent Mental Health, Older Peoples Mental Health, Primary Care and Specialist Services), do not qualify as reportable segments as decisions about the allocation of resources and the assessment of performance are not made at this level by the Board. The Anglia Support Partnership provided shared support services to other NHS organisation within the local health economy. The Board assesses the performance of the operating segments based on a measure of net surplus and EBITDA. The Board do not receive a breakdown by segment for the the Trust's performance in terms of interest receivable or payable, depreciation or amortisation and any other material non-cash items. Other information provided to the Board, except as noted below, is measured in a manner consistent with that in the accounts. The financial split per organisation is : 2012/13 Healthcare Anglia Support Partnership Total '000 '000 '000 Income 132, ,286 Segment Surplus Net Assets 73,016-73, /12 Healthcare Anglia Support Partnership Total '000 '000 '000 Income 135,730 28, ,075 Segment (Deficit) 1,027-1,027 Net Assets 72,761-72,761 Anglia Support Partnership was sold to Serco Limited with effect from 13 April 2012, and therefore was not a continuing business segment at 31 March Page 33.

45 Cambridgeshire and Peterborough NHS Foundation Trust - Annual Accounts 2012/13 NOTES TO THE ACCOUNTS NOTE 35 THIRD PARTY ASSETS The Trust held cash at bank and in hand at 31 March 2013 of 345,000 (31 March 2012: 404,379) which relates to monies held by the Trust on behalf of patients. This has been excluded from cash at bank and in hand figure reported in the accounts. NOTE 36 CAMBRIDGE UNIVERSITY HEALTH PARTNERS Cambridge University Health Partners (CUHP) was designated an Academic Health Science Centre by the Department of Health in March The entity became fully established as a company limited by guarantee on 11th September 2009, with CPFT (as one of the four partners) underwriting 25% of the guarantee costs. The objectives of CUHP are to drive forward the partnership between the National Health Service (NHS) and the University of Cambridge. The Trust has accepted as part of the members agreement an recurrent funding requirement of 103,300 (2011/12: 102,000), however the agreement requires unanimous confirmation of partners for any additional funding. In view of the arrangements set out in the members agreement with CUHP, the Trust considers CUHP to be an Associate. However it has not been accounted for under the equity method as it is the Trust s view that the investment is not material. NOTE 37 DISPOSAL OF ACCOUNTING SEGMENT On 13 th April 2012, the Trust signed an agreement with Serco Limited to transfer the Assets and staff of the Anglia Support Partnership to Serco plc. The key elements of the transaction are as follows; A transfer of the existing business from CPFT including contracts, assets and staff; Simultaneous with the transaction occurring a procurement Framework Contract is being established by CPFT, under which Serco will be the exclusive provider. There is an existing partnership between a group of founder members of ASP and Essex Partners, a group of other significant customers to ASP. A partnership Board is to be created as part of the new arrangements with Serco and certain of the existing partners which will direct the strategy of the business post transaction including generating new business. The NHS partners will thereby participate in some of the additional costs and benefits of the business post transaction. The figures disclosed for discontinuing activities exclude intra company transactions between ASP and CPFT. NOTE 38 CAMBRIDGESHIRE MENTAL HEALTH AND PRIMARY CARE TRUSTS CHARITABLE FUND The Trust is currently Corporate Trustee to Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund, a Charity registered with the Charities Commission (Charity No ). The Charitable Fund includes funds in respect of all the Cambridgeshire and Peterborough NHS Foundation Trust (formerly Cambridgeshire and Peterborough Mental Health Partnership NHS Trust) services and the services of the following Trusts: Cambridgeshire Community Services NHS Trust NHS Cambridgeshire NHS Peterborough The objective of the Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund is for the Trustee to hold the funds upon trust to apply the income, and at its discretion, so far as may be permissible, the capital, for any charitable purpose or purposes relating to the National Health Service. The main policy followed is that the majority of the expenditure is incurred for the support and improvement of patient services and to provide further comforts for patients which cannot be afforded through public funding. HM Treasury has granted dispensation to the application of IAS 27 (revised) by NHS foundation trusts solely in relation to the consolidation of NHS charitable funds for 2011/12 and 2012/13 and therefore the activities of the Charity have been excluded from these accounts. Page 34.

46 Agenda Item: 7 BOARD OF DIRECTORS MEETING REPORT Subject: Date: 24 th May 2013 Author: Trust Secretary Lead Director: Chief Executive Draft Annual Report Executive Summary: It is a statutory requirement that CPFT prepare an annual report (Schedule 7, paragraph 26 of the NHS Act 2006). A draft of the Annual Report has previously been circulated to the Board for comments. Since that draft was circulated the main changes have been additions to the Chairman s statement, the CUHP section and revised tables for the Remuneration Report. This is the final version of the Annual Report for the approval of the Board. Recommendations: The Board of Directors is asked to: Consider and approve the Annual Report Authorise the signing of the Annual Report Relevant Strategic Priorities (please mark in bold) Our services will be recognised as world class We will develop service plans that achieve financial stability We will develop our built environment and technology infrastructure to We will deliver care through engaged and empowered people We will develop strong relationships based on trust and mutual respect with key stakeholders

47 deliver our vision Links to BAF/Corporate Risk Register Details of additional risks associated with this paper (may include CQC Essential standards, NHSLA, NHS Constitution) Financial implications/impact Legal implications/impact Partnership working and public engagement implications/impact Committees/groups where this item has been presented before Has a QIA been completed? If yes provide brief details It is a statutory requirement that CPFT as a Foundation Trust produces an Annual Report. The Report includes examples of CPFT s partnership working and public engagement. Audit Committee 22 nd May 2013 Introduction The purpose of this report is to seek the approval of the Board for the Annual Report of Cambridgeshire and Peterborough NHS Foundation Trust for Background It is a statutory requirement that CPFT prepare an annual report (Schedule 7, paragraph 26 of the NHS Act 2006). The annual report of NHS foundation trusts must, as a minimum, include: a directors report including a management commentary; a remuneration report; the disclosures set out in the NHS Foundation Trust Code of Governance; a quality report; staff survey; regulatory ratings; income disclosures required by Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012); other disclosures in the public interest; a statement of Accounting Officer s Responsibilities; and an Annual Governance Statement. The annual report must be formally approved by the board of directors. NHS foundation trusts are required to lay their annual report and accounts, with any report of the auditor on them, before Parliament (paragraph 25(4)(a)), Schedule 7 of the 2006 Act) before the summer recess begins in July 2013 to enable parliamentary scrutiny.

48 The Annual Accounts, Quality Account and Annual Governance Statement which are all incorporated into the Annual Report are being considered as separate agenda items at today s Board meeting. Recommendation The Board of Directors is asked to: Consider and approve the Annual Report Authorise the signing of the Annual Report

49 Annual Report and Accounts Cambridgeshire and Peterborough NHS Foundation Trust

50 Cambridgeshire and Peterborough NHS Foundation Trust Annual Report and Accounts Presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the National Health Service Act 2006

51 Contents 1. Chairman s statement Directors report 2.1 History, purpose and vision 2.2 Directors report: business review. 2.3 Research and development activities Education and training activities 2.5 Working with partners. 2.6 Principal risks and uncertainties 2.7 Progress against organisational objectives. 2.8 National and local targets 2.9 Financial performance Trends and factors likely to affect future developments, performance and position Meeting our responsibilities 2.12 Improving patient care and safety. 3. Council of Governors 3.1 The Council of Governors. 3.2 The composition of the Council of Governors 3.3 Register of interests.. 4. Board of Directors 4.1 Non-Executive Directors 4.2 Executive Directors Appointment of the Chairman and Non-Executive Directors Register of interests Audit and Assurance Committee. 4.6 Business and Risk Committee. 4.7 Quality and Healthcare Governance Committee 4.8 Quality and Performance Committee Nominations Committee Governors Nominations Committee Remunerations Committee Board and Committee Effectiveness 5. Membership 5.1 The membership 5.2 The public membership 5.3 The patient membership The staff membership Membership numbers Membership strategy Page 1

52 6. Public interest 6.1 Consultation with and involvement of employees. 6.2 Equal Opportunities, disabled employees Health, safety and occupational health 6.4 Counter-fraud policies 6.5 Consultations with local groups and organisations Other public and patient involvement activities. 6.7 Information on NHS sickness data Cost statement 6.9 Compliance with the NHS foundation trust code of governance 6.10 Information on serious incidents (SIs) involving data loss or confidentiality breach 6.11 Statement on the NHS Constitution.. 7. Remuneration Report 7.1 Remuneration committee 7.2 Remuneration and performance conditions. 7.3 Duration of contracts, notice periods and termination payments. 8. Quality Report to be inserted 8.1 Statement on quality from the Chief Executive. 8.2 Introduction. 8.3 Priorities for improvement 8.4 Priority 1 XXXXXXX 8.5 Priority 2 XXXXXXX 8.6 Priority 3 XXXXXXX 8.7 Priority 4 XXXXXXX 8.8 Priority 5 XXXXXXX 8.9 Statements of assurance from the Board of Directors Review of services Participation in clinical research Education and training 8.13 Participation in clinical audits 8.14 Use of the CQUIN payment framework Care Quality Commission (CQC) registration and compliance 8.16 Data quality Review of quality performance Statements from NHS Cambridgeshire, Governors, local involvement network and overview and scrutiny committees 8.19 Annex: statement of directors responsibilities in respect of the quality report 8.20 Draft independent assurance report Feedback on the quality report and accounts. 9. Staff survey report 9.1 Summary of performance results from the national NHS staff survey Regulatory report 10.1 Monitor s regulatory ratings 11. Equality and diversity statement 12. Statement of Chief Executive s responsibilities as the Accounting Officer of Cambridgeshire and Peterborough NHS Foundation Trust Page 2

53 13. Annual governance statement to be inserted 14. Cambridgeshire and Peterborough NHS Foundation Trust s Annual Accounts Year ended 31 March 2012 to be inserted This report is based upon guidance issued by the Independent Regulator of NHS Foundation Trusts and was approved by the Board of Directors on 24 May Signed Attila Vegh Chief Executive Page 3

54 1 Chair s statement has been an incredible year for CPFT. We have experienced lows and highs and it is extremely pleasing to report that we end the financial year in an extremely positive mood. After the challenges and huge changes we faced in , it is with great pleasure we can announce that we are fully compliant with the Care Quality Commission. The Cavell Centre in Peterborough was also found to be fully compliant in all areas after an inspection in December Achieving full compliancy across the Trust represents a huge achievement on behalf of all the staff, Board, service users and carers. It is through their hard work and dedication over the past 12 months that we have managed to turn around the performance of CPFT. We have seen major changes in the physical environments of the CPFT and major changes in the attitude of our staff. Their performance has been exemplary. Our next challenge is to keep this momentum going and not to become complacent. Standards must remain high, and I am confident we have the right attitude and right staff to achieve this and become the leading provider of local health services. CPFT also created a little bit of history this year. As you will be aware, the Trust was put in significant breach by health regulator Monitor last year. However, in March 2013, after a year of huge turnaround, we received the news from our regulator that it had removed us from significant breach. This is one of the quickest turnarounds an NHS Trust has ever achieved. Staff have been under huge pressures this year and it never fails to amaze us how they keep raising care standards. All the plaudits for this turnaround must go to them and we are sure they will continue to deliver high-quality services to those who need them. Our Board has also seen major changes. Anne Campbell, who had been Chair of the Trust for nearly seven years, retired in During this time, Anne has overseen the transition to Foundation Trust status and also the Trust becoming a founder member of Cambridge University Health Partners - making us one of the leading academic NHS trusts. Anne also saw the establishment of one of the biggest peer support networks in the country, offering support to our service users whilst helping them get back into employment. I know I speak on behalf of everyone in wishing her all the best for the future. We also said goodbye to Prof Ian Goodyer, Ashish Dasgupta and Terry Holloway who had all served on the Board for many years and made an invaluable contribution to the organisation. We welcomed four new Non-Executive Directors in 2013 Julie Spence, Sir Patrick Sissons, Julian Baust and John Lappin. Julie was the former Chief Constable of Cambridgeshire Police and has more than 30 years experience in public service. Sir Patrick is a distinguished clinician and academic who has worked in university medical schools for more than 30 years. Julian is a former chairman and managing director of Kodak, and John is a finance director with more than 30 years commercial experience, principally with Royal Mail and now with the Care Quality Commission. I believe we have made some great appointments it was extremely important to get first-class individuals on board and I believe we have done that. Despite all this work going on behind the scenes, I d like to highlight some of the incredible work our staff have been doing with service users and carers on the frontline over the past 12 months. Page 4

55 During the summer, Kate Brown, one of our physios, put on a superb Fulbourn mini- Olympics, which saw staff, service users and carers taking part in all sorts of indoor and outdoor activities. We even took part in our own torch relay around the grounds of the hospital, cheered on by spectators. It was fantastic event and one enjoyed by all on what was a very hot day. CPFT launched Recovery College East - the east of England s first recovery college at the end of The college is a collaborative, educational learning environment that will enable people who use, or have used, secondary services from the Trust to develop new skills and increase their understanding of the mental health challenges they have. The Ministry of Defence announced that CPFT will continue to provide local in-patient mental health care for serving military personnel in the eastern region following a competitive tendering process. This is fantastic news for the Trust The Cavell Centre in Peterborough has been providing this service since 2009 so it was great we can continue to provide high-quality and effective in-patient care that is tailored to the specific needs of armed forces personnel serving worldwide. Another CPFT service the Child and Adolescent Substance Use Service (CASUS) was awarded the contract to provide an integrated drug and alcohol misuse service across Cambridgeshire. The CASUS team was also awarded the Virgin Business Media and Guardian s innovation award for collaboration in 2012 a wonderful achievement for the team. Our Dementia Carers Support Service also won a Cambridge News Community Award in 2012 in the community group category. CPFT opened a new state-of-the-art dementia research facility at Fulbourn Hospital. Newly-refurbished Windsor House will provide a clinical room and interview room where researchers can carry out assessments on site. This facility is a collaboration between the Trust and staff from the Dementia and Neurodegenerative Diseases Research Network. Two of our in-patient services received accreditation in The Croft Child and Family Unit was accredited by Quality Network for In-patient Child and Adolescent Mental Health Service. Oak 2 Ward at The Cavell Centre received Accreditation for In-patient Mental Health Services (AIMS) by the Royal College of Psychiatrists. These are fantastic achievements by both services. Our Youth Offending Service was put in the top five nationally after being praised by HM Inspector of Prisons and the Care Quality Commission. The team s work was considered to be some of the best in the country. Throughout the year we honour staff who act above and beyond the call of duty in monthly Quality Hero awards. I have been privileged to attend the last two ceremonies and it has been inspiring listening to the work undertaken by my Trust colleagues. In February, we also held our first stand-alone annual staff awards ceremony in Cambridge. Nearly 200 staff attended to see who had won out of the eight categories. The atmosphere was amazing it s always a pleasure being able to acknowledge colleagues who do some amazing work on top of their normal day jobs and I look forward, at next year s event, seeing what they achieve over the next 12 months. Page 5

56 CPFT is a member of Cambridge University Health Partners (CUHP) a partnership between CPFT, the University of Cambridge, Papworth Hospital and Cambridge University Hospitals NHS Foundation Trust. This partnership delivers world-class excellence in health care, research and clinical education to improve health for the people of Cambridgeshire and beyond. CUHP itself is one of only five Academic Health Science Centres in England recognised by the Department of Health as internationally competitive centres of excellence in the integrated delivery of health care. It is a huge honour to be part of this collaboration and testament to our extensive portfolio of research projects. We very much look forward to continuing that work and driving forward new clinical programmes and innovative health pathways within the partnership. The new Eastern Academic Health Science Network (EAHSN) has been rightly praised for its innovative approach in engaging four geographical areas under the new network, building real strength in depth. The new Board chaired by Sir Michael Rawlins and his deputy Stephen Thornton reflected quality at every level. It gives us the opportunity to intervene further down the transitional pathway to encourage real improvement in the quality of services on the ground. The board is fully engaged in this new initiative. The year ahead will be just as challenging as the one just past. We are working in a radically new healthcare system embracing clinical leadership, which I welcome. The new commissioners have a desire to work differently, with less money and to meet ever rising public expectation. I welcome the commitment to Integrated Care, hopefully across Health and Social care. It maybe through this initiative the system can address the funding deficit for Mental Health given the population challenges we face. We will work together to achieve the aim of better, joined up services for the people we serve. The ministerial commitment to putting mental and physical health as areas of equal importance is also welcomed. It s imperative we don t get complacent and we must sustain the momentum we have built up over the past year. We are all excited by what lies ahead and I know our staff are ready for whatever challenges are thrown at them. These are just some of the highlights it is down to our staff who have turned this Trust around over the past 12 months. There s one thing for certain CPFT will be playing a crucial part in the local health and social care system. On behalf of the Board of Directors and Council of Governors, I d like to thank staff for their work in caring for the people who need our services in Cambridgeshire and Peterborough and putting this Trust on the road to becoming one of the top NHS organisations in the country. David Edwards OBE Chairman Page 6

57 2. Directors report The Directors report is being presented in the name of the following directors who occupied Board positions during the year and includes a business review. Name Title 1 Anne Campbell Chair 2 David Edwards OBE Chair 3 Tom Abell Director of Service Improvement and Chief Information Officer 4 Barbara Beal Director of Nursing 5 Darren Cattell Interim Director of Finance 6 Melanie Coombes Director of Nursing Ashish Dasgupta MBE Non-Executive Director Chess Denman Medical Director Robert Dixon Non-Executive Director 7 Ian Goodyer Non-Executive Director 8 Terry Holloway Non-Executive Director 9 Barbara McLean Director of Nursing 10 Derek McNally Acting Director of Finance 11 Lucy O Brien Non-Executive Director 12 Jenny Raine Director of Finance and Performance 13 Mick Simpson Interim Chief Operating Officer 14 Sir Patrick Sissons Non-Executive Director 15 Julie Spence OBE Non-Executive Director Keith Spencer Director of People and Business Development Attila Vegh Chief Executive Further information on directors is detailed under section History, purpose and vision Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) was formed on 1 June 2008 under the Health and Social Care (Community Health and Standards) Act 2003 succeeding the Cambridgeshire and Peterborough Mental Health Partnership NHS Trust. 1 Chair until September Chair from September Director of Service Improvement and Chief Information Officer from April Director of Nursing from April to November Interim Director of Finance from July Director of Nursing from November Non-Executive Director until December Non-Executive Director until March Chief Operating Officer and Director of Nursing until April Acting Director of Finance from May to June NED until June Director of Finance and Performance until April Interim Chief Operating Officer from April Non-Executive Director from January Non-Executive Director from January 2013 Page 7

58 Our core purpose is to provide excellent mental health, specialist learning disability and children s community services for our patients across Cambridgeshire and Peterborough and in some service areas beyond this geographical boundary. We also provide some specialist services on a regional and national basis. Our services include: child and adolescent mental health services children s community services in Peterborough adult mental health services older people's mental health services forensic and specialist mental health services substance misuse services specialist learning disability services improving access to psychological therapies liaison psychiatry and unexplained symptoms Our approach to the provision of services is governed by a philosophy of recovery and will be designed and delivered with the following principles in mind wherever possible: Focus on people rather than services Build hope and aspiration with our service users Emphasise strengths rather than emphasise deficits or dysfunctions Educate people who provide services schools, employers, and the media and members of the public to combat stigma Foster collaboration between people who need support and people who support them Promote autonomy through enabling and supporting self management and, as a result, decrease the need for people to rely on formal services and professional support. Our mission We deliver exceptional care that we are proud to recommend to our family and friends. Our values Patients first we focus on the needs of our patients. We aim to exceed their expectations by making every interaction count. Our staff matter we trust, value and develop each other. We build a great place to work, where people are inspired to be the best they can be. Only the best we have high standards in all that we do. We are uncompromising in our pursuit of excellence. We measure everything we do and share the data with others to judge. We expect that everyone will give the best they can. Together, as one we are good people to do business with. We value our teams and our partners and believe together we can achieve more. We focus our efforts only on what we can become best at. Page 8

59 Our vision We become a top five mental and community healthcare provider delivering best-inclass care, research and education. We will deliver this vision by transforming CPFT into an integrated mental and community health and long-term conditions organisation. Our aspiration is to become a major provider of out-of-hospital care in the east of England. Our role as partners in Cambridge University Health Partners, one of only five Academic Health Science Centres in the UK, gives new opportunities to work more collaboratively with the member organisations, the University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, Papworth NHS Foundation Trust and CPFT. The links with Cambridge University Hospitals NHS Foundation Trust will be increasingly important as breakthroughs in mental health research and neuroscience enable us to develop more of our inpatient services on the Cambridge Biomedical Campus site. 2.2 Directors report: business review Overall performance The Trust began the year with having made significant improvements in complying with the CQC Essential Standards of Quality and Safety overcoming many challenges. However, it remained non-compliant with Outcome 1, treating people with respect. Focused efforts continued to improve practice and performance against this standard and the Trust was reassessed in February 2013 and found fully compliant against all standards for the first time since The Trust was also taken out of significant breach of its terms of authorisation with Monitor, the Foundation Trust regulator in March 2013, having delivered upon a wide-ranging programme of improvement in terms of governance and risk management. Both these declarations have put the Trust in a strong position for driving forward further improvement in delivery of high-quality services for the year ahead. Future quality improvement priorities In December 2012, we launched our Quality Diamond Strategy which sets out four objectives to turn Cambridgeshire and Peterborough NHS Foundation Trust to be a top five mental and community healthcare provider. The Quality Report, see section 8 for full report, sets out our future priorities. New performance and risk management framework The Trust has continued in its development of a robust and comprehensive performance and risk management framework during the course of the year. This has been supported with further work on revising and strengthening our performance reporting including the introduction of integrated reporting across a range of indicators in the themes of safety and effectiveness, patient experience, staffing, and resources. We have also reconfigured our reporting to realign to the operational divisional structure, producing three monthly dashboards for Acute, Community and Specialist Services to provide a focus for performance monitoring and opportunities for service improvements. Monthly performance and risk meetings are held with each division that ensure direct accountability for operational service delivery through clinical directors, general managers and nurse leads. Page 9

60 Patient Survey The National Service User Survey was undertaken for Cambridgeshire and Peterborough NHS Foundation Trust between February and June Responses were received from 254 service users. Results from the 2012 survey, demonstrate continuing good progress compared against 2011 results. Based on a comparison with the 2011 question responses, the following is highlighted from the 2012 survey: 62% improved 31% remain static 5% deterioration 2% no comparable data Those questions where there have been some very positive and significant improvements in question scores for 2012 include: Were the purposes of medication explained to you? increase of 10% from 61% (2011) to 71% (2012). Were you given information about the medication in a way that was easy to understand - increase of 15% from 40% (2011) to 55% (2012). Do you understand what is in your NHS care plan? - increase of 16% from 42% (2011) to 58% (2012). Have you been given (or offered) a written or printed copy of your NHS care plan? increase of 13% from 53% (2011) to 66% (2012). Of the small percentage of question scores where there has been some decline, the question: Has a mental health or social care worker checked with you how you are getting on with your medication?, is of most note with a decrease of 6% from 78% (2011) to 72% (2012). Overall, in comparison with other Trusts who took part in the 2012 CQC Community survey, the Trust has been rated by the CQC as about the same for all question groupings. Source: Quality Health/CQC website. Information on complaints handling Complaints, PALS enquiries and compliments comparative figures Complaints PALS enquiries Compliments The Trust continues to work and support clinical teams in responding to issues or concerns and a number of changes and improvements have been made in response to complaints that have been raised with us. Quality performance and assessment The Integrated Compliance Assessment tool (InCA) was introduced during the course of the year to support the assessment of our compliance position against the Page 10

61 CQC outcomes and support the overall awareness-raising of essential standards across our wards and community teams. The tool encompasses all the requirements of the CQC standards along with the transformation tools and standards that were developed as part of our turnaround programme. The tool was rolled out in phases during the year starting firstly with inpatient units and later to community service teams. Service developments Acute Care System The implementation of the new Acute Care System serving the adult population of Peterborough, Huntingdon and Fenland was completed early in the financial year. This new system incorporated the acute inpatient wards and the crisis and home treatment teams serving the north of the county. The primary driver to the reorganisation was to improve the patient experience and ensure effective use of the available resources. This was achieved through careful redesign of the patient pathway within the inpatient setting to ensure that service users, their carers and staff all have a very clear understanding of what will be achieved in a particular ward as each ward has a specific function. The pathway is structured in three stages, assessment, treatment and recovery, each with a nominal timeframe. The system is designed to reflect the presenting needs of service users and to ensure that the interventions from staff are delivered in a timely manner minimising the amount of time patients have to spend in hospital. A key element of the new system is the interface between the home treatment teams and the assessment unit. The implementation of the new system required staff to change practice considerably and to develop an extended range of clinical skills which they have managed to do very successfully. The feedback from service users and from referrers during a review of the system in June 2012 was very positive. The model is being implemented in the south of the county in early Advice and Referral Centre (ARC) This year saw the implementation of a single point of referral for the Peterborough area as part of the implementation of a single trust-wide point of access. This is a major initiative requiring considerable reorganisation of patient pathways across all adult and older people s services. A significant part of the task was to work alongside primary care colleagues to ensure that the system was valuable to them in helping to access appropriate services for their patients. The service is being rolled out incrementally across the organisation having expanded from the first stage in Peterborough to incorporate Fenland and then rolling out to the Huntingdon area to be extended across the whole trust by mid The implementation of the single point of access has led to a much more consistent and timely response to referrals. It has also generated a consistent approach to information gathering improving the quality of referrals due to standardised information from GPs. The first stage of the implementation in Peterborough was reviewed with local GPs who have found the single point of access to be very beneficial. Recovery College East This year saw the development of CPFT s Recovery College East in collaboration with other partner organisations and led by CPFT. The college is primarily for mental health service users or people who have used secondary services in the recent past. The college is developing specific courses for carers and for staff from other Page 11

62 organisations such as primary care or sheltered housing. Recovery College East provides a collaborative educational learning environment and aims to convey messages of hope, empowerment and opportunity to all. The college is committed to ensuring open access to all students and all courses are co-produced and codelivered involving at least one person with lived experience of mental health problems. Courses take place at a range of community venues across Cambridgeshire and Peterborough. FACE (Frequent Attenders Care Enhanced) This is a new service initiative developed in response to concerns about the small number of frequent attenders at Accident and Emergency departments. A small multi-disciplinary pilot team has been operational for the last 12 months to meet the needs of those people who are chronically excluded for mainstream services but present on a regular basis to emergency services. These presentations do not address the underlying causes of their attendance and the FACE team aims is to comprehensively assess and agree management plans with multi-agency involvement to meet the person s on-going needs. The initial period has been successfully evaluated and has secured continued funding for a further 12 months to enable the service to continue whilst a more detailed evaluation is completed. Treatment resistance affective disorder pathway As part of pathway redesign a new clinical service for patients with resistive to treatment affective disorder as been developed. This is a specialist service approach for service users with long and or recurrent uni-polar depression. This service model involves intervention from senior psychotherapists and psychiatrists and other professionals working within a single specialist team. The aim of the service is to provide highly specialised treatment to that small patient group who have not responded to routine treatments previously. Children and Adolescent Psychiatry Intensive Support Team During the year a new community service for young people was established mirroring the adult service Crisis Home Treatment model called the Intensive Support Team. This team provides intensive support and home treatment to a small number of adolescent patients aged 13 to 18, who might otherwise require inpatient treatment. This is a trust-wide service which aims to enhance our ability to treat these young people in the least restrictive setting. The team works closely with the existing Child and Adolescent Mental Health (CAMH) services as part of an expanded care network. Family support and improving family dynamics are key parts of the teams work. The service has been received positively and there has been a significant reduction in hospital admissions following the introduction of the initiative. Health Visiting Service There has been signification development in the Health Visiting Service in Peterborough due to the Trust s proactive engagement in the national health visiting programme (Call to Action) which aims to double the number of health visitors across the country by The Trust is part of the major national programme to recruit and train more health visitors which is closely monitored with an annual target for new trainees. The Trust trained 10 new student health visitors during the year and has recruited a further 18 to participate in training during the coming year, which is in line with the demanding national target set by the national body. In conjunction with this development the opportunity has also been taken to develop the existing health Page 12

63 visitor workforce through targets leadership training and enhanced supervision programme Primary mental health for older people This initiative was provided with dedicated funding to develop services which provide psychological interventions for people with mild or moderate mental health problems, particularly those with the early stages of dementia. The service includes memory clinics and screening of people with acute hospital and GPs to identify early signs of memory problems increasing in the number of referrals of people access the memory assessment services. Awards and accreditation National quality accreditation schemes provide a way of assessing the quality of our services and comparing our performance with other Trusts across the country. They provide assurance that our services are meeting the highest standards set by the professional bodies, and also provides us with a framework for quality improvement. During , CPFT participated in a wide range accreditation schemes run by the Royal College of Psychiatrists. Full details of our the services that have achieved accreditation status can be found in the quality report in section Valuing our staff and our partners Staff awards During the course of the year the Trust has continued to recognise the significant contribution of its staff in the delivery of direct care for those who need our services. The Trust is committed to acknowledge and reward good performance of its staff based on their merits. Two key initiatives that have been introduced include Quality Heroes and Team Champions. CPFT also celebrated its first Annual Staff Awards in February to appreciate the outstanding achievements of our staff. Nominations were received across eight categories and a strong field of very worthy examples of outstanding contributions were evident. 2.3 Research and development activities was a progressive year for R&D in CPFT with a number of significant achievements to report. We recruited more patients into clinical research studies than ever before; We initiated the mental health theme of the Cambridge Comprehensive Biomedical Research Centre (BRC); We implemented the pilot phase of a new IT programme to improve research and audit access to clinical records We continued to streamline and enhance processes for R&D governance by a team that is closely integrated with the larger R&D management team in CUHT We radically refreshed the R&D website and increased the engagement of service users and carers in all aspects of the Trust s research activity. Page 13

64 Patient recruitment into clinical research studies, recognised as part of the NIHR Portfolio, was estimated to be about 1100 at the time of this report. This is the largest number of patients annually recruited from CPFT services into clinical research since NIHR started monitoring activity in It also clearly beats our recruitment target (800) for the year and indicates strongly growing R&D activity in CPFT at a time when R&D activity in many other mental health trusts is in decline. This is therefore an outstanding achievement for CPFT overall. In particular it is notable that much of this activity has ben driven by major new grants in relation to impulsivity and compulsivity (Dr Valerie Voon; Wellcome Trust Intermediate Fellowship) and in relation to adolescent brain and mind development (Professor Ian Goodyer et al; Wellcome Trust Strategy Award). The Cambridge BRC is a major NIHR investment in clinical research locally and, since June 2012, CPFT has benefitted for the first time from some funding for this source; 250k / year for five years. In , we focused this new investment on procuring, ethically approving, and technically implementing a software system (CRIS) that will allow researchers, managers and clinicians to get much easier access to anonymised clinical data. A pilot phase of testing the software has just begun and, if positive, we expect the CRIS system to be deployed in co-ordination with CPFT s strategy for new clinical records information systems in 2013 and beyond. We anticipate that this development will substantially enhance the capability of CPFT to identify patients that are potentially suitable for future studies, which is likely to be of major benefit to academic partners and in the competition to win business from the pharmaceutical industry. Importantly, the CRIS software was originally developed by the South London and Maudsley NHS Trust and it is being adopted by three other specialist mental health trusts (in Oxford and London). Thus there is a strategic opportunity for CPFT to develop its clinical research capacity via CRIS as part of a technically linked cluster of leading centres in the south east. CLAHRC s (Collaboration for Leadership in Applied Health Research and Care) bid for funding to support research in integrated healthcare and immediate (T2) translation of the research knowledge base into benefits for patients in CPFT and elsewhere in the region is being led by Prof Peter Jones. New academic leads will be appointed to work closely with the clinical directors in the new divisional structure, with responsibility for managing investment of CLRN income so that teams and activities that are generating or likely to generate NIHR portfolio research activity are identified and supported effectively A new strategic fund will be created, pooling the RCF income to CPFT together with an approximately matching contribution from CPFT central budgets, to be invested primarily in senior clinicians who want to develop research-orientated, innovative services. Allocation of this strategic fund will be supervised by Sir Patrick Sissons and will be prioritsed in the thematic areas of dementia, biomedicine and mental health, and informatics. Together with CUHP, we will build the R&D governance capability of CPFT, especially in relation to conduct and sponsoring of clinical trials of (new) investigational medical products (CTIMPS) We expect to exceed this year s record-breaking patient recruitment numbers and further increase the range and depth of R&D in the Trust. Page 14

65 2.4 Education and training activities CPFT continues to provide multi-disciplinary postgraduate education and training with the East of England Deanery (now LETB). We have a highly regarded postgraduate training programme for psychiatry and train doctors from Foundation Year up to readiness to apply for consultant. We were particularly pleased that one of our higher trainees, Dr Malar Sandilyan, was the Eastern Region 2012 Trainee Research Prize Winner for the Royal College of Psychiatrists. Our training programmes have strong links to the University of Cambridge and CUHP, and we have several postgraduate medical academic trainees developing both clinical and research skills. Our trainees have published in a wide range of areas including psychosis, information technology, dementia, teaching and risks for depression. As part of our reorganisation CPFT is launching an academy, bringing together medical, clinical and leadership skills, and training to shape the future of the Trust. The aims of this exciting new development include developing a culture of learning and growth through active promotion and support of personal development and implementing an integrated, multidisciplinary training, learning and development portfolio. Revalidation This year saw the introduction of one of the most important changes in the way that doctors are regulated since the original Medical Act of Doctors are now subject to a regular annual process of appraisal that inspects the quality of their practice and, once every five years, this information is reviewed by the General Medical Council and doctors whose practice is satisfactory are "revalidated" and allowed to continue to practice medicine. CPFT has complied with the introduction of revalidation. All doctors have for some years had regular appraisals and in the past year these have been enhanced to take account of the new requirements of this process for the purposes of revalidation. Dr Chess Denman, Medical Director, acts as the "Responsible Officer" for the GMC and makes recommendations about doctors to the GMC. CPFT anticipates making its first tranche of revalidation recommendations by the end of April Working with partners and stakeholders We have well-established and innovative partnership relationships with our key statutory partners. We are formal partners in Peterborough Children's Partnership Trust Board, Peterborough Local Children's Safeguarding Board, Peterborough Learning Disability Partnership Board, the Cambridgeshire Children and Young People's Strategic Partnership Board, Cambridgeshire Local Children's Safeguarding Board, Safeguarding Adults Board, Cambridgeshire Learning Disability Partnership board and Cambridgeshire Care Partnership board. Key senior staff are also members of the SHA clinical programme boards for mental health and for children. Page 15

66 Academic Health Science Centre Cambridge University Health Partners (CUHP) In March 2009, CPFT, in partnership with the University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, and Papworth Hospital NHS Foundation Trust, was designated an Academic Health Science Centre (AHSC) by the Department of Health. This designation followed a national competition in which only five centres in England were successful in demonstrating excellence in clinical care, research and education at a level that placed them in the international premier league of academic health organisations. The model of governance for the Cambridge Academic Health Science Centre is through a partnership organisation, Cambridge University Health Partners (CUHP). This was established as a company limited by guarantee in November The objects of CUHP are to improve patient care, patient outcomes, and population health, through innovation and the integration of service delivery, health research and clinical education. The Chairman and the Chief Executive of CPFT are ex officio directors of CUHP, as are the Vice-Chancellor of the University of Cambridge, the University Registrary and the Regius Professor of Physic. There are also three further directors with both clinical and academic responsibilities, one linked with each of the NHS trusts. The Board Chairman is Professor Sir Keith Peters FRS. The Executive Director until September 2012 was Professor Sir JG Patrick Sissons, Regius Professor of Physic. From September 2012 onwards, it is Professor Patrick Maxwell, Regius Professor of Physic CUHP employs a small core team and the cost of this is shared equally between the four partners. In , CPFT s contribution to cost of running CUHP was 103,300. The constitution of CUHP reserves a range of matters to the members or the Board of Directors as a means of ensuring that its activities are directed towards its objects at all times and that members are not exposed to any unanticipated risks through participation. CUHP also managed the Cambridgeshire and Peterborough Health Innovation and Education Cluster (HIEC) under contract from NHS East of England until 31 March 2013 when this work ceased. In extending and developing the successful CUHP model, there are plans to enlarge the partnership with the inclusion of major organisations including the Cancer Research UK (part of the University of Cambridge); the new Laboratory of Metabolic Science (LMB2) and other biomedical and biotechnical enterprises that will form the Cambridge Biomedical Campus as it develops over the next five years. In the focus for CUHP has been to lead on the development of an Academic Health Science Network for the East of England (EAHSN). The development of the EAHSN was led by CUHP on behalf of 20 organisations serving a population of 4.5 million. The model is radical and different and will build on the strengths of the four natural clinical communities. The partnership encompasses the M11 and A1 corridors thus forming one of the biggest bioscience and med-tech clusters outside the United States. The EAHSN has now appointed a Chair, Professor Sir Michael Rawlins, and a Vice Chair, Stephen Thornton, and the network looks to have a productive and synergistic relationship with CUHP, especially in relation to both pharmaceutical and small- to medium-sized enterprises. Page 16

67 The new EAHSN will present a unique opportunity to align education, clinical research, informatics, innovation, training and education and health care delivery. Under this arrangement, CUHP will be nested within the EAHSN. CUHP s mission will remain as healthcare, research and clinical education. In , the CUHP Board defined the areas of strategic importance to the partnership as: Research Clinical education The development of a CUHP charity The development of the Cambridge Biomedical Campus. Regional service innovation will be led by the EAHSN with CUHP focussing on clinical quality within the partnership. CUHP will work with both the Cambridge and Peterborough node of the EAHSN and the EAHSN as a whole. A number of initiatives have been developed in under the clinical education portfolio including a new endorsement scheme for short continuing professional development courses. The scheme, which has considered a number of applications in its first year, tests robustly the quality of proposed educational activity against an assurance process ensuring that courses carrying the CUHP endorsement are of the highest educational quality in design and delivery. 2.6 Principal risks and uncertainties CPFT is able to demonstrate compliance with the corporate governance principles that the Board of Directors maintains a sound system of internal control to safeguard public and private investment, the NHS Foundation Trust s assets, patient safety and service quality through its Board Assurance Framework (BAF). As part of our governance improvement initiatives in , the Board revisited its approach to the operation of the BAF to ensure that it was fit for purpose and aligned with the new arrangements for risk management within the organisation. Following these changes, the BAF is now an integral part of the overall risk management framework which is now in operation within the Trust. It has a clear link into the performance management process within the Trust, codified within the Divisional Accountability and Governance Agreements, alongside the Trusts Framework for Quality Governance. The BAF is reviewed quarterly by both the Quality and Performance Committee as well as the Board, with the responsible Executive Director for the risk being identified. The BAF identifies the key controls in place to manage each of the principal risks and explains how the Board of Directors is assured that those controls are in place and operating effectively. The Board of Directors receive regular reports that detail the quality, financial and performance issues that are arising within Trust operations, and where required the action being taken to address any identified weakness. These include monthly quality, financial and operational performance reports, quarterly reports on performance against our objectives and governance declarations to Monitor on compliance with our Terms of Authorisation. Page 17

68 The Quality and Performance Committee is a sub-committee of the Board, chaired by a Non-Executive Director. It meets monthly to review risks to our business objectives, alongside the quality, performance and financial governance and performance requirements within the Trust. The committee provides assurance to the Board on the overall performance of Trust operations taking into account a holistic view of quality, performance and finances. The Audit and Assurance Committee s role is to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across CPFT is able to demonstrate compliance with the corporate governance principles that the Board of Directors maintains a sound system of internal control to safeguard public and private investment, the NHS Foundation Trust s assets, patient safety and service quality. An internal audit takes place annually to review our risk management processes. The BAF is reviewed on a quarterly basis, with risk registers being reviewed on a monthly basis at all levels of the organisation to ensure that it provides a means to support the effective and focused management of the principal risks to meeting our strategic objectives. Page 18

69 Risk description Patient safety compromised as a result of us not being able to meet demand for Trust services. Mitigation The Trust has clinical risk assessments in place for all referrals and the overall waiting lists for services. For areas where risk has been identified, action plans are being implemented to manage waiting lists to safe levels. The Trust has in place a redesign process to understand the level of service which can be provided within available resources alongside on-going work with our commissioners on the future funding and shape of service provision. Patient safety compromised as a result of us being unable to safely staff our wards. Operational staffing meetings are in place to regularly review and confirm staffing levels across all inpatient units. Dedicated and on-going recruitment campaign to nursing posts to reduce vacancy levels within the Trust. Trust-wide project in place to confirm and challenge establishment levels with operational teams. Improvement project implemented in regard to the activities of the Operation Centre to improve fill rate for unfilled shifts. Failure in operational delivery as a result of the transition to the new service structures and associated redesign work. The overall service design and transition work is being managed through a Project Management Office (PMO) supported project, with dedicated resource being allocated to the project alongside enhanced monitoring systems through our PMO project governance structures. A Quality Impact Assessment is in place for the service change projects which are reviewed regularly by clinical leaders and reported alongside project status reports on a fortnightly basis. Governor, staff, patient and commissioner engagement has been a central element of the development of the redesign and implementation proposals. Inability to meet our financial commitments as a result of the under delivery of the cost improvement programme and the changing commissioning environment. All divisions have identified cost improvement projects in order to deliver the required level of savings in , delivery. Delivery of CIP implementation is through the CIP and Re-organisation Task and Finish Groups with day to day financial delivery of budget being monitored with Divisions through the Performance and Risk Executive. 2.7 Progress against organisational objectives In the past year since the annual plan was developed, overall good progress has been made against the objectives. The Board set six key priorities with 18 Page 19

70 deliverables. Summary performance against these deliverables is given in the table below: Key priority To provide safe and effective care that provides an excellent customer experience Year-end Status GREEN To provide an estate and IT infrastructure that is safe, modern and fit for purpose To provide services through empowered staff with the right skills, attitudes and behaviours and who are engaged with the vision, values and key objectives of the Trust To meet our financial obligations as an NHS Foundation Trust To develop a culture and system of sound governance, personal accountability and earned autonomy To develop a reputation as a good and responsible organisation to do business with AMBER AMBER/RED GREEN AMBER/ GREEN TO BE CONFIRMED Improving patient safety, service effectiveness and the patient experience We were able to achieve almost all of our CQUIN goals as set by our Lead Commissioners, (NHS Cambridgeshire and NHS Peterborough). We have performed well against the national targets as set out in the operating framework. CQUIN GOALS Goal 1 Theme: NHS Safety Thermometer Improve collection of data in relation to pressure ulcers, falls, urinary tract infection with a catheter, and VTE. Performance The Trust has carried out monthly NHS Safety Thermometer surveys of wards for older people and learning disabilities ward. Quarter 1: Achieved 97.6% harm-free care Quarter 2: Achieved 98.8% harm-free care Quarter 3: Achieved 97.1% harm-free care Quarter 4: Achieved 98.2% harm-free care Page 20

71 Goal 2 Theme: Dementia Improve awareness and diagnosis of dementia by training staff in other local NHS providers. Indicator 1 Number of dementia training sessions delivered to each provider Trust highlighted above to enable these service providers to deliver their provider specific CQUIN schemes relating to dementia. Indicator 2 Improve access to prompt advice and support for people and their carers recently diagnosed or identified as potentially at risk of dementia following screening in hospital or community services. Goal 3 Theme: Patient experience Improve responsiveness to personal needs of patients. Indicator 1 To ensure that providers have real time systems in place to monitor patient experience. Indicator 2 To demonstrate improvements in patient experience using the Net Promoter Score (NPS). Goal 4 Theme: Making every experience count Clinical staff working in the agreed areas have appropriate knowledge and skills to make to make a brief advice intervention for alcohol/smoking or both and to signpost or refer as appropriate in line with the making every contact count Initiative. Goal 5 Theme: Measuring outcomes Indicator 1 The Trust has, in collaboration with all acute providers within the locality, developed and implemented over 70 training sessions. Key outcomes: Feedback received shows that 95% of participants learnt lot about the subject as a result of the training 86% of participants reported a change in their attitude and approach to people with dementia. Indicator 2 There is initial evidence to show that referrals to liaison services within CUHFT (Cambridge University Hospitals NHS Foundation Trust) have increased as a result of the training. Indicator 1 CPFT has developed, with Meridian, a webbased patient survey system to routinely collect real-time patient experience data across all inpatient and community teams using ipads. Results are discussed at our monthly Divisional Performance Review meetings with clear lines of accountability up to the Trust Board Indicator 2 The Trust s overall average NPS across the three divisions range between 34% (April 2012 score) to 55% (August 2012 score), with an average of 47% for the year (which is the same as the March 2013 score). This shows a 13% increase from the baseline figure in April We provide an e-learning training package to our staff within the Rehabilitation and Recovery Pathway to equip them with the knowledge and skills to engage with their patients around healthy lifestyle issues and refer them on to the appropriate agency, where required. As of March 2013, not all the staff in this pathway have completed the training which has resulted in non compliance of this target. The Trust will continue to roll out the e-learning package to the remainder of staff in early 13/14. CAMH IAPT: Our staff have been trained in undertaking the CYP-IAPT Outcomes Page 21

72 Routine reporting of outcome measures for each of CAMH (IAPT), Adult (Recovery Star) and OPMH CORE 10 and QALY AD. Goal 6 Theme: Perinatal mental health Delivery of NICE guidelines for priority access to IAPT for pregnant and postnatal women. Goal 7 Theme: Learning disability Improve access to mental health services for people with learning disability, based upon the annual self-assessment of progress that CPFT has completed and reinforcing the subsequent action plan. Goal 8 Theme: ADHD Training of core staff within Intake and Treatment Teams in diagnosis and advice on patient management for ADHD. Measures during We encountered a number of challenges around putting the technology in place but by Q4 the necessary systems were in place to support greater usage of outcomes measures in Adult: During we trained over 80% of our staff within the Rehabilitation and Recovery Pathway to use the Recovery Star which gets a patient to look at recovery as a journey with different stages. Using this approach has led to a change in the culture, care delivered and supporting documentation resulting in better outcomes for the patient. OPMH CORE 10/QALY AD: 70% of service users in the specified pathways have undertaken the specified outcome measures. As per the NICE Guidelines we give priority access to perinatal patients with the average waiting time across the locality being 25 days during The Trust has continued to deliver against the Learning Disability Performance Indicators Access to Healthcare Action Plan. CPFT staff have delivered ADHD training to staff within the Department of Psychiatry and the Intake and Treatment Team during , based on training materials developed through CPFT and the University of Cambridge. Growth CPFT met all its income growth targets for the year. Key developments included: Acquired Peterborough Community Children s Services Won tender to deliver Multi-Systemic Therapies in Northamptonshire Won contract to deliver inpatient beds to the United States Air Force Opened up new Complex Cases Unit at Fulbourn Living within our means Despite it being a difficult operating environment, CPFT achieved its financial targets and a financial risk rating of three. Page 22

73 Developing a skilled and engaged workforce CPFT continues to be successful in managing the targets in relation to reducing sickness absence and compliance with appraisal targets. Mandatory training provides a challenge for the Trust but plans are in place to monitor and ensure staff complete mandatory requirements. Leadership Develop Programmes have continued to be developed and supported. The Trust again developed and hosted the Countywide Festival of Leadership initiative. This includes a range of seminars and master classes for NHS and social care leaders in the local health area. The Trust is currently working on the following to enhance skills and development: New competency frameworks for all staff A new performance management framework including enhancing appraisal and supervision Capability and competency leadership assessments for ward managers and clinical leads The volunteering department is now fully functioning and proceeding with the recruitment of volunteers to specific roles across the Trust Six Peer Support Worker cohorts were completed with 32 peers now in post and the Trust is continuing to create further peer worker roles. Two peer worker educators are now in post Skill-mix reviews are being undertaken across the Trust to ensure establishments are appropriately structured An operations centre has been established to provide support to the Trust to ensure effective staff rostering and the supply of quality temporary staff where required. 2.8 National and local targets The Trust is required to achieve a number of key national priorities as outlined within the Department of Health Operating Framework. The Trust performed well in against these targets: Target (%) Target Target LOCAL TARGET Service users seen within 18 weeks (CPFT target) 100% 100% 100% 100% NATIONAL TARGETS Care Programme Approach (CPA) patients receiving follow-up contact within seven days of discharge 16 95% 95% 96.67% 95.24% CPA patients having formal review within 12 months 95% 95% 99.60% 95.97% Minimising delayed transfers of care <= 7.5% <= 7.5% 1.42% 3.88% Admissions to inpatients services had access to crisis 90% 95% 91.74% 95.24% The mandated national indicators have been subject to external audit. 16 Care Programme follow-up The indicator is expressed as a the proportion of those patients on Care Programme Approach (CPA) discharged from inpatient care who are followed up within 7 days. Patients discharged includes patients discharged to their place of residence, care home, residential accommodation, or to non psychiatric care, or to prison. The indicator excludes patients who die within 7 days of discharge, patients removed from the country as a result of legal precedence, patients transferred to NHS psychiatric inpatient ward when discharged from inpatient care and CAMHS (children and adolescent mental health services), i.e. patients aged under 18. Those that are recorded as followed up receive face to face contact or a telephone conversation (not text or phone messages). The 7 day period is measured in days not hours and starts on the day after discharge Page 23

74 resolution home treatment teams 17 Meeting commitment to serve new psychosis cases by early intervention teams 95% 95% 100% 100% Data completeness: identifiers 99% 99% 99% 99% Data completeness: outcomes 50% 50% 72% 97.32% Data completeness: Community services referral to 50% 100% treatment information Referral information 50% 98.9% Treatment activity information 50% 99.6% Patient identifier information 50% 97.6% Self-certification against compliance with requirements regarding access to healthcare for people with a learning disability No threshold set No threshold set MRSA Infection rate (per 1000 bed days) C.Difficile Infection Rate (per 1000 bed days) Met Met 2.9 Financial performance Overview of results for the year Overall the Trust performed well and has delivered a surplus of 0.9m in the year and an operational surplus for the year of 4.7m. This has resulted in a Financial Risk Rating of 3 against the Monitor Risk Rating metrics, which is better than the plan for the year. The Trust s cash balances remain sound, and were ahead of plan at 31 March as a result of a profit on the disposal of the Cobwebs site in Cambridge. The Trust has lived within its capital expenditure plan for the year and this reflected the development of improved governance around the Trust s process and the recruitment of an in-house estates team. Significant events since Statement of Financial Position There have been no significant events since the date of the Statement of Financial Position Statement regarding audit 17 Access to crisis resolution home treatment teams The indicator is expressed as proportion of inpatient admissions gatekept by the crisis resolution home treatment teams in the year ended 31 March The indicator is expressed as a percentage of all admissions to psychiatric inpatient wards. The following patients are excluded from the indicator: Patients recalled on Community Treatment Order, transferred from another NHS hospital for psychiatric treatment, Internal transfers of service users between wards in the trust for psychiatry treatment, Patients on leave under Section 17 of the Mental Health Act and Planned admission for psychiatric care from specialist units such as eating disorder unit. An admission is reported as gatekept by a crisis resolution team where they have assessed* the service user before admission and if the crisis resolution team were involved** in the decision-making process which resulted in an admission. * An assessment should be recorded if there is direct contact between a member of the team and the referred patient, irrespective of the setting, and an assessment made. The assessment may be made via a phone conversation or by any face-to-face contact with the patient. ** Involvement is the assessment of all patients thought to be requiring admission other than those detained under the Mental health Act., although seen out of hours between 10.00pm 08.00am Where the admission is from out of the Trust's area and where the patient was seen by the local crisis team (out of area) and only admitted to this Trust because they had no available beds in the local areas, the admission is recorded as gatekept if the CR team assure themselves that gatekeeping was carried out. Page 24

75 As far as the directors are aware there is no relevant audit information of which the auditors are unaware and each director has taken all of the steps that they ought to have taken as a director to make themselves aware of any relevant audit information and to establish that the auditors are aware of that information. Going concern statement 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. For this reason, they continue to adopt the going concern basis in preparing the accounts. Retirement and other benefits Accounting policies for pensions and other retirement benefits are set out in note 4 of the accounts. Details of senior employees remuneration can be found on page xx of the remuneration report. During the year there were eight early retirements from the Trust ( :: 3) agreed on the grounds of ill-health. The estimated additional pension liabilities of these ill-health retirements will be 559,859 ( : 401,196). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division. External auditor s remuneration and fees and disclosure of non-audit work The Trust has paid 62,000 to the external auditors, PricewaterhouseCoopers (PWC), for audit services (statutory audit) in the financial year. In addition to this the Trust also paid its auditors 15,000 for its assurance work on the quality report (audit-related regulatory reporting) The Trust also engaged PWC to complete a review of the Trust Quality Governance Framework as part of process of addressing the Trust s breach of the terms of its authorisation. The value of this work was 414,000. When considering whether the Trust engages the auditors to undertake non-audit work, the Trust consider a number of areas of potential threat to PricewaterhouseCooper s independence as the Trust s external auditors. In each area the Trust considers if there is a potential threat and, if there is, whether appropriate safeguards can nonetheless be implemented to maintain the auditor s independence. If threats exist that cannot be appropriately safeguarded, the Trust would not offer the additional work to the auditors. The areas of potential threat considered are as follows: Self interest threat arising from the auditors having an interest in the outcome of the work Self-review threat that the auditors might later need to perform audit work on the auditors own work Management threat - the auditors might take decisions on behalf of the Trust Advocacy threat - the auditors might be seen to be acting in partnership with an audit client Familiarity threat - that the auditors team may become overly close to management. Page 25

76 Better payment practice codes The Trust is committed to making payments to suppliers within the timescales required by the code. In , the Trust paid 85% of invoices within 30 days of invoice date ( , 91%). The Trust had no payments of interest under the Late Payment of Commercial Debts (Interest) Act Market values of fixed assets All Trust property and land assets are revalued on an existing use value, which in the opinion of the Directors is not significantly different from the assets market value. Raising issues or concerns The Trust as an organisation is committed to the seven principles of public life, expounded in the Nolan Committee report. The commitment of the Trust to probity and public service values manifests itself in the following: the promotion of an ethical environment. the maintenance of an Audit and Assurance Committee with clear terms of reference and unrestricted scope. the operation of a remuneration committee. the use of clearly defined and documented policies. compliance with statutory financial reporting requirements. operation of an effective accounting and budgetary control system. an adequate and effective internal audit function. putting in place appropriate internal controls. holding regular public meetings. investigating all cases of alleged fraud and corruption. nomination of a Local Counter-Fraud Specialist (LCFS). All staff have a duty to protect the assets of the Trust. Assets include information and intellectual property as well as tangible items. Every Director or member of staff of the Trust has a responsibility to ensure that any suspected incidence of fraud, financial irregularity or corruption is identified and reported appropriately. Any Director or member of staff who is aware of, but does not report, any suspected fraudulent or corrupt act is condoning the act. It should be noted that all Directors or staff have a duty to comply with HSG (93) 5 Standards of Business Conduct for NHS Staff as well as the 2002 Code of Conduct for NHS Managers. Where the Trust incurs a loss arising from a fraudulent or corrupt act of a Director or employee the Trust will seek redress and where appropriate compensation. Statement on the preparation of the accounts Monitor, the independent regulator of NHS Foundation Trusts, in exercise of powers conferred on it by paragraphs 24 and 25 of Schedule 7 of the National Health Service Act 2006, directs that the keeping of accounts and the annual report of each NHS Foundation Trust shall be in the form as laid down in the annual reporting guidance for NHS Foundation Trusts within the NHS Foundation Trust Annual Reporting Manual, known as the FT ARM, that is in force for the financial year. Page 26

77 The Trust has complied with this and the accounts are prepared in accordance with this direction Trends and factors likely to affect future developments, performance and position The financial overview above explains the background to our financial position at the end of We have carefully reviewed the background and taken into account the following external factors in developing our new strategy and business plan for and beyond: The changing NHS commissioning environment with the creation of new commissioning organisations for our services. The changing regulatory and oversight requirements that will be placed on the Trust as a result of the on-going changes at Monitor and the CQC as our two principle regulators. Everyone Counts: Planning for Patients as published by NHS England. The forecast increase in demand for our services as a result of demographic and other population changes within the areas we serve. The anticipated NHS financial environment for the future, with continuing efficiency challenges being required of NHS organisations. Further detail on these issues is available within our Annual Plan as submitted to Monitor and within the revised Trust Strategy which will be published in the summer. Future developments We will take forward our vision over the next three years through the four elements of the Quality Diamond: Patient safety Patient experience Staff experience Value for money The specific things we plan to do to secure improvements across these four areas are included within the Annual Plan we submit to Monitor which will be further outlined within the Trust Strategy published in the summer Meeting our responsibilities Page 27

78 Monitoring improvements in the quality of healthcare The Trust has undergone significant changes in the way in which it monitors quality across the services it provides. This has involved the introduction of an overarching performance and risk framework and includes the production of a monthly integrated performance dashboard, monthly divisional performance meetings, divisional accountability agreements and authorisations and exception reporting of performance themes and risks. A new quality monitoring tool (Integrated Assessment Tool) has also been launched to help wards and community teams to fully understand and monitor compliance against the CQC essential standards and incorporates the previously introduced turnaround tools and standards including the 5 stars, REV and 7Cs. We have strengthened our internal governance systems and processes to ensure oversight and scrutiny of quality and finance which have been overseen by Board and its sub-committee the Quality and Performance Committee. Care Quality Commission (CQC) The Trust participated in compliance reviews during the year. In February 2012 the Care Quality Commission found that the Trust was compliant in all areas of previous concern, but one moderate concern in relation to Outcome 1. Following an inspection and a table-top exercise in December 2012, CPFT was judged fully compliant with the CQC Essential Standards for Quality and Safety. As of March 2013, the current registration status of CPFT with the CQC is registered without conditions. The Quality Report describes our actions and priorities for quality improvement. The Quality Report is available on page 60. Page 28

79 3. COUNCIL OF GOVERNORS 3.1 The Council of Governors The Council of Governors was established in June It has developed into and continues to be an effective body that brings the views of our patients, the public, partner and stakeholder organisations, and our staff to inform CPFT s strategy. The Council of Governors fulfils a number of formal functions which include: Appointment of the Chair and other Non-Executive Directors of the NHS Foundation Trust Appointment or removal of the external auditor Consultation on forward plans Receiving the Annual Report and Accounts and the auditor s report 3.2 Composition of the Council of Governors The Council of Governors consists of 25 elected governors and 14 appointed governors. The elected governors represent different constituencies of membership, namely public (15 governors), patient (four service users and two carers) and staff (four governors). Elected governors Public Governors, Cambridgeshire - representing and elected by the public members living in Cambridgeshire. Three vacancies John Cranston Elected in July 2011 for a term of office to June 2014 Ms Jane Fasham Re-elected in July 2011 for a term of office to June 2014 Mr Bernie Gold Re-elected in July 2010 for a term of office to June 2013 Mrs Margaret Johnson Elected in July 2011 for a term of office to June 2014 Ms Karimah Rodney Elected in July 2011 for a term of office to June 2014 Mr Colin Shaw Elected in July 2011 for a term of office to June 2014 Public Governors, Peterborough - representing and elected by the public members living in Peterborough. Mrs Diane Armitage Elected in July 2010 for a term of office to July 2013 Mr Ian Arnott Re-elected in July 2010 for a term of office to July 2013 Mr Michael Farmiloe Elected in July 2011 for a term of office to June 2014 Mr Edward Murphy Elected in July 2010 for a term of office to July 2013 Mr Chris York Elected in July 2012 for a term of office to July 2015 Public Governor, Rest of England - representing and elected by the public members living in the Rest of England - vacant Service User Governors representing and elected by current and past service user members. Cambridgeshire: Lauren Levine Elected in July 2010 for a term of office to June 2013 Peterborough: Mr Phil Staton Elected in July 2012 for a term of office to June 2015 Page 29

80 Rest of England: Vacant Carer Governors - representing and elected by carer members living in Cambridgeshire, Peterborough and the Rest of England Mrs Jemima Atkinson Mrs Elizabeth Mitchell Elected in July 2010 for a term of office to July 2013 Elected in July 2012 for a term of office to July 2015 Staff Governors - representing and elected by the staff members of CPFT Ms Tracey Tingey Ms Ayla Humphrey Mr Kailash Ludhor Mr Rod Rivers Elected in July 2012 for a term of office to July 2015 Elected in July 2011 for a term of office to June 2014 Elected in July 2010 for a term of office to July 2013 Elected in July 2010 for a term of office to July 2013 Appointed Governors Our appointed Governors are key stakeholders in the work of CPFT. These posts are appointed by the respective organisation to represent their views in the governance of CPFT. Name Organisation Term started Paul Cawkwell Representative of Prisons: HMP July 2012 Littlehey, HMP Whitemoor, Peterborough Prison Maureen Donnelly NHS Cambridgeshire July 2010 Ms Janet Feary Local Involvement Networks (LINks) November 2008 Ms Brenda Hennessy Cambridge University Hospitals NHS July 2010 Foundation Trust Mr Hywel Jarman Hinchingbrooke Healthcare NHS June 2008 Trust Mr Paul Fulwood Cambridgeshire Constabulary February 2012, replacing Gary Ridgway Mr Paul Phillipson Peterborough City Council December 2009 Ms Clare Wilson Peterborough and Stamford Hospitals NHS Trust January 2011 Governor resignations The following governors left the Council of Governors during the course of the year: Patient Governors: Mr Phil Barton, Service User Cambridgeshire, resigned in December 2011 Page 30

81 Mr Barry Monk, Service User Peterborough, deceased January 2012 Public Governors: Dr Elizabeth O Donnell, Cambridgeshire, resigned in September 2011 Rev David Parkes, Peterborough, resigned in July 2011 Dr Geoffrey Sweet, Cambridgeshire, resigned in February 2012 Staff Governor: Ms Carol Evans, resigned in February 2012 Appointed Governors: Mr Hywel Jarman, Hinchingbrooke Hospitals NHS Trust, December 2011 Mr Gary Ridgway, Cambridgeshire Constabulary, January 2012 Governor elections Electoral Reform Services Limited (ERS) acts as the returning officer and independent scrutineer of the election process. Results of the annual general election were declared on 26 June 2011: Public Peterborough: Michael Farmiloe, Chris York Patient: Carers: Elizabeth Mitchell Patient: Service User, Peterborough, Phil Staton Staff: Tracey Tingey Results of the Annual Election for 2013 will be declared on 18 June Attendance at Council of Governor Meetings The Council of Governors hold formal public meetings up to four times a year. During the last year a total of seven formal meetings were held in public. Name Title Attendance out of 4 (unless otherwise stated) Anne Campbell Chair until September /1 David Edwards Chair September /3 Diane Armitage Public Governor 3 Ian Arnott Public Governor 3 Jemima Atkinson Carer Governor 2 Phil Staton Patient Governor 3/3 John Cranston Public Governor 4 Chris York Public Governor 3 Michael Farmiloe Public Governor 2 Jane Fasham Public Governor 2 Janet Feary Appointed Governor 2 Bernie Gold Public Governor 4 Page 31

82 Name Title Attendance out of 4 (unless otherwise stated) Brenda Hennessy Appointed Governor 2 Ayla Humphrey Staff Governor 1 Margaret Johnson Public Governor 3/3 Kailash Ludhor Staff Governor 2 Tom Mackinnon Appointed Governor 2/2 Paul Fulwood Appointed Governor (replacing Tom Mackinnon) 2/2 Edward Murphy Public Governor 2 Paul Phillipson Appointed Governor 4 Rod Rivers Staff Governor 4 Karimah Rodney Public Governor 1 Colin Shaw Public Governor 3 Diana Wood Appointed Governor 2 Paul Cawkwell Appointed Governor 2 Meeting dates: 4 th July 2013, 19 th September 2012 (Annual General Meeting) 5 December 2012, 13 th March 2013 The Council of Governors invite Directors and Non-Executive Directors to attend all Board of Governor meetings. Directors and Governors working together There are regular opportunities for Directors and Governors to work together in committee and working groups, including review of the constitution, the annual plan and the quality turnaround programme. Involving and understanding the views of Governors and members The Board of Directors welcome opportunities to involve and listen to the views of Governors and members. Listed below are activities that promote engagement: Members voting in (and standing for) elections for the Council of Governors Governors attendance at the Annual Members Meeting Member events through membership talks, and events on annual plan development Member engagement through CPFT Membership Office Directors available before meetings of the Council of Governors 3.3 Register of Interests All Governors are asked to declare any interests on the Register of Governors Interests at the time of their appointment or election. There is a standing item on all Council of Governor and Committee meetings to ensure that all interests relevant to the meeting are declared. This register is held by the Trust Secretary. The register is available for inspection by members of the public. Anyone who wishes to see the Register of Governors interests should make enquiries to the Trust Secretary at the following address: The Trust Secretary, CPFT Headquarters, Elizabeth House, Fulbourn Hospital, Cambridge CB21 5EF. Page 32

83 4. BOARD OF DIRECTORS The Board of Directors comprises both full-time Executive and part-time Non- Executive Directors. The role of the Board of Directors is to manage the Trust by: Setting the overall strategic direction Being accountable for the performance and stewardship of CPFT Ensuring CPFT provides high quality, safe and effective services Ensuring high standards of governance exist across all Trust activities Promoting effective dialogue between CPFT and the communities it serves 4.1 Non-Executive Directors Anne Campbell Chair until September 2012 Areas of special interest / responsibility: Chair of both the Board of Directors and the Council of Governors of CPFT, and also chaired the Remuneration and Terms of Service and Council of Governor Nominations committees Anne Campbell was the Chair of CPFT between December 2005 and September From 2007 to 2009 she was the elected Vice-Chair of the Mental Health Network of the NHS Confederation. She is currently a Director of Cambridge University Health Partners, which is an academic health science centre comprising the University of Cambridge, Cambridge University Hospitals, Papworth Hospitals Foundation Trust and Cambridgeshire and Peterborough NHS Foundation Trust. She was previously the Labour Member of Parliament for Cambridge from 1992 until She held positions as Parliamentary Private Secretary to both John Battle when he was Science Minister and to The Right Honourable Patricia Hewitt when she was Secretary of State for Trade and Industry. From 1985 to1989 she was an elected member of Cambridgeshire County Council. Anne s earlier career as a mathematician and statistician was spent teaching at Anglia Ruskin University and at the National Institute of Agricultural Botany as Head of Statistics and Data Processing. She is an Honorary Fellow of Newnham College Cambridge and holds an Honorary Doctorate from Anglia Ruskin University. Anne has an Honours Degree in mathematics from the University of Cambridge. She is a Fellow of the Royal Statistical Society and a Fellow of the Royal Society of Arts. David Edwards OBE Chair from September 2012 Chair of both the Board of Directors and the Council of Governors of CPFT, and also Chair of the Remuneration and Terms of Service and Council of Governor Nominations committees David has worked in health care for 44 years. He recently chaired the health commissioning body NHS Great Yarmouth and Waveney. Prior to that, he was a Non-Executive Director of James Paget University Hospital Foundation Trust. He currently chairs the Norfolk and Suffolk Dementia Alliance, is vice-chair of the UEA Governing Council and in a board member of UCS. In his executive life, he was Chief Executive of University Teaching Hospitals in Birmingham, Nottingham and Cardiff for more than 20 years. Page 33

84 Ashish Dasgupta Non-Executive Director Area of special interest/responsibility: Chair of the Audit and Assurance Committee and member of the Remuneration and Terms of Service Committee Ashish came to England from India in 1962 with a degree in Economics, Law and Accountancy. He studied in London to qualify as an accountant and became a fellow of the Chartered Institute of Management Accountants. He is also a fellow of the British Institute of Management. In 1967, Ashish joined Philips Electronics, the Dutch multi-national, as a junior accountant, and he spent most of his working life with the company. He worked for almost all of the product divisions, rose through the ranks and first became a director in After spending a few years in components, private telephony and then in the Industrial Electronics Divisions as Group Financial Director, Ashish joined the Radio Communication Division as group financial director in In this capacity, he had responsibility of the finance, treasury and IT functions of the worldwide business. He then became managing director and was responsible for the worldwide business of the Private Mobile Radio Group. Philips divested from this business in 1995 and Ashish became managing director of Philips Car Systems. In this role, he was responsible for introducing the first in-car satellite navigation system to the UK. Ashish retired from Philips in 1998 and since then has devoted himself to a number of commercial and charitable activities. He has served as Non-Executive Director of the NHS for more than ten years, firstly in the East Anglian Ambulance Trust and currently in Cambridgeshire and Peterborough NHS Foundation Trust. In his other charitable and community work, Ashish is trustee and director of the Papworth Trust, the Varrier Jones Foundation and the Pye Foundation. He served as a magistrate in Cambridge for eight years. Ashish also owns and runs a small consultancy company and is currently non-executive chairman of a software company. As a member of The Worshipful Company of Information Technologists, Ashish became a Freeman of the City of London in 2006 and a Liveryman in He was awarded an MBE in Robert Dixon Non-Executive Director Area of special interest / responsibility: Chair of the Quality and Performance Committee, member of the Audit and Assurance Committee Robert Dixon is currently the sole proprietor of a consultancy practice specialising in strategic marketing and business development advice/interim management services to the medical/healthcare related sectors. He is currently acting as part-time interim CEO of the Bladder and Bowel Foundation a UK-wide patient advocacy and support charity. He is also chairman of an early stage medical technology enterprise involved in novel intellectual property and product development; and a senior associate of an international marketing organisation serving clients in the medtech and socially disadvantaged sectors. Over the course of his career, Robert held a number of executive management roles in marketing and business development of increasing seniority within the global medical device industry sector. This included project and product management for Johnson & Johnson during the 1970s; moving to Vickers Medical and then to Page 34

85 Coloplast A/S in 1984 as UK Marketing Manager and later as European Marketing Manager. In 1996, Robert became Marketing Director (Europe) for Hollister Inc, a large employee-owned USA-based global medical device manufacturer and was a member of its European Management Committee and global Corporate Product and Process Committee. His career has involved holding responsibility for strategic and annual business planning, accountability for marketing and product development strategy and implementation, and managing the transition from technical research and development through to commercial launch. Robert has voluntary and charity sector experience as a parent-elect, and later LEAappointed School Governor; working with groups representing people with physical disabilities; and with advocacy groups dealing with long-term medical conditions. Professor Ian Goodyer Non-Executive Director until December 2012 Areas of special interest / responsibility: Ian Goodyer is a Professor of Child and Adolescent Psychiatry at the University of Cambridge, and is also an Honorary Consultant at CPFT. In 1987 he became the first university Lecturer in Child and Adolescent Psychiatry at Cambridge University and subsequently in 1992 he became the first holder of the Professorship of Child and Adolescent Psychiatry. From Ian was the first Director of Research and Development for Cambridgeshire and Peterborough Mental Health Partnership NHS Trust. Ian has represented the university and the NHS on numerous scientific and healthcare committees and research boards at the Medical Research Council, Wellcome Trust and Department of Health. He has also advised the UK and Canadian Governments on policy for child and adolescent mental health. Terry Holloway Non-Executive Director until March 2013 Areas of special interest / responsibility: Senior Independent Director, Chair of the Charitable Funds Management Panel, Chair of the Remuneration and Terms of Service Committee. Terry Holloway is the Group Support Executive at Marshall of Cambridge working as Executive Assistant to Chair and Chief Executive since He was formerly a Senior Royal Air Force Officer. Terry possesses considerable business experience including HR, commerce, business strategy, change management, marketing and PR, team building and leadership, and introduction of LEAN (production practice creating more value for customers with fewer resources). He has strong leadership and management experience, in both public and private arenas, and has a strong record in the financial and investment areas. His considerable charitable and community experience includes being a Council Member for Cambridgeshire St John Ambulance and Chair of Cambridge Business Community Action Network. Terry is Fellow of the Royal Aeronautical Society (UK), Deputy Chair of the Air League and is involved with the Air Training Corps within Cambridge. He is a Page 35

86 Freeman of the City of London and a Livery Member of the Guild of Air Pilots and Air Navigators since Lucy O Brien Non-Executive Director until June 2012 Areas of special interest / responsibility: Chair of the Mental Health Act Committee (until January 2012)member of the Quality and Healthcare Governance Committee and Business Risk Committee. Lucy O Brien is a graduate of the University of Surrey (BSc Human Biology), a member of the Chartered Institute of Public finance and Accountancy (CIPFA) and is a Neuro Linguistic Programming practitioner. She has five years' experience as Accountant and Company Secretary in a privately owned start-up, and later AIM-listed, medical company where she was responsible for developing the accounting and quality systems and focused on fund-raising. She has nine years' experience as a senior finance manager in the NHS, in management accounting and training roles. Lucy also has experience working with the National Audit Office, scrutinising Government expenditure and developing value-for-money audit protocols. Sir Patrick Sissons Non-Executive Director from January 2013 Areas of special interest/responsibility: Research and Development strategy development Professor Sissons has worked in university medical schools in clinical academic positions for more than 30 years - latterly as Regius Professor of Physic and Head of the School of Clinical Medicine at the University of Cambridge. He demonstrates a vast knowledge regarding how translational research and medical education can contribute to high-quality clinical services, and strengthens our vital link to the University of Cambridge. Julie Spence OBE Non-Executive Director from January 2013 Areas of special interest/responsibility: Improving customer and patient experience, sensitising the criminal justice system to mental health issues, positive leadership and supporting staff to deliver high quality services. Julie Spence has more than 30 years' distinguished public service in the police service, most recently as Chief Constable of Cambridgeshire Constabulary. She has a very good understanding of the NHS and is used to operating with high levels of public accountability and public scrutiny. She has excellent local networks and partnerships that will benefit CPFT and demonstrates a real passion for the people of Cambridgeshire and Peterborough. 4.2 Executive Directors Tom Abell Director of Service Improvement/Chief Information Officer Areas of responsibility: Performance management, risk management, IT infrastructure, estates infrastructure and management Tom joined CPFT in April 2012 from NHS South Essex where he was Director of Commissioning. In his current role he is responsible for ensuring that the Trust s Page 36

87 estate provides the best possible experience for users of our services, our IT services enable our people to work more effectively and that the Trust s internal performance management systems drive forward the quality of care we provide to our service users. Barbara Beal Interim Director of Nursing from April 2012 to November 2012 Areas of responsibility: Nursing professional leadership and clinical management throughout CPFT Barbara Beal is an experienced nurse who worked as a Nurse Director and a General Manager at provider and commissioner level, and at the Department of Health before joining CPFT as interim Director of Nursing. Darren Cattell Interim Director of Finance from July 2012 Areas of responsibility: Finance and procurement including financial reporting, financial control, payroll, audit and procurement, capital planning, financial performance and management Darren completed a significant period of time as Interim Director of Finance and Performance at Mid Staffordshire NHS Foundation Trust. Darren's recent background is in challenged provider and commissioner organisations and brings a wealth of experience in balancing the demands of investing in the quality of services and saving money. Melanie Coombes Director of Nursing from November 2012 Areas of responsibility: Nursing professional leadership and clinical management throughout CPFT Melanie was appointed in November 2012 after five years as Deputy Director of Nursing and then Acting Director of Nursing at Coventry and Warwickshire Partnership Trust. She has been a Registered Nurse for 24 years and has worked in a variety of nursing roles including Nurse Consultant in Learning Disabilities Dr Chess Denman - Medical Director Areas of responsibility: Responsible Officer for medical revalidation; Consultant appraisal; clinical research development and governance; clinical effectiveness and medicines management; Caldicott Guardian Dr Denman is a consultant psychiatrist and psychotherapist. Dr Denman trained in medicine at Trinity College, Cambridge, and London University before studying psychiatry at Guys and St Thomas' Hospitals and at the Cassel Hospital in London. She then became consultant psychiatrist in psychotherapy, first at Addenbrooke's and then at CPFT. Dr Denman founded the Complex Cases Service 12 years ago for treatment of personality disorders within CPFT and it won pilot site and now innovation site status from the Department of Health along with substantial funding to expand after three years. Recently the service expanded to include one of only two in-patient units within the NHS for personality disordered patients. Dr Denman has published papers, articles and a book on personality disorder, the organisation of psychotherapy services and human sexuality. Barbara McLean Chief Operating Officer and Director of Nursing until April 2012 Areas of responsibility: All clinical and operational services across CPFT Page 37

88 Barbara has a long career in mental health nursing, service management and commissioning for mental health and learning disability services. She was previously with the Suffolk Mental Health Partnership NHS Trust as Director of Nursing. Barbara has extensive experience having worked for the East of England Strategic Health Authority developing health services in criminal justice in collaboration with the Department of Health and Home Office. Derek McNally Acting Director of Finance from May to June 2012 Areas of responsibility: Finance and procurement including financial reporting, financial control, payroll, audit and procurement, capital planning, financial performance and management A member of the Chartered Institute of Management Accountants (CIMA), Derek has 25 years experience within NHS finance, and has held a number of senior finance positions across a range of healthcare organisations over the past 20 years. He has been Deputy Director of Finance and Performance for the Trust since 2005 and was Acting Director of Finance and Performance May June 2012 Jenny Raine Director of Finance and Performance until May 2012 Areas of responsibility: Finance and procurement including financial reporting, financial control, payroll, audit and procurement, estate management, capital planning, financial performance and management Jenny qualified as a chartered accountant with Pricewaterhouse Coopers and joined the NHS more than ten years ago. Since that time Jenny has had a number of senior finance positions, the most recent of which was Deputy Finance Director of Lifespan Healthcare NHS Trust. Jenny has been with CPFT since just after it was founded and during that time was the Deputy Director of Finance and Performance. Mick Simpson Interim Chief Operating Officer from April 2012 Areas of responsibility: All Clinical and Operational Services across CPFT Mick has been a mental health nurse for 34 years with experience across a broad range of services and care settings. He has worked in mental health services in Cambridgeshire for more than 20 years and has held a number of operational management positions during that time Keith Spencer Director of People and Business Development Areas of responsibility: Strategy development, business planning, business development, commissioning, marketing and client management, service transformation, information systems, information technology, information management, information governance. Human Resources, learning and development, leadership and management development; workforce equality and diversity; workforce productivity, temporary staffing, medical services Keith is a graduate of the University of Warwick and a Chartered Fellow of the Chartered Institute of Personnel and Development. He was formerly Managing Director of Anglia Support Partnership (ASP), one of the biggest NHS Shared Support Service organisations in the country. He has held board positions in both the public and private sectors including a major software house and as Director of HR and Corporate Development at Lifespan Healthcare NHS Trust. He has a particular interest in strategic development and innovation strategies. Page 38

89 Dr Attila Vegh Chief Executive Areas of responsibility: Responsible for meeting all the statutory requirements of CPFT, in addition to being CPFT s Accounting Officer to Parliament. Attila is a qualified medical doctor. He practiced internal medicine and later completed his PhD in molecular cancer research. He holds an MSc in Health Management from Imperial College London. From 2009 Attila was the Managing Director of NHS South West Essex Community Services, successfully leading the organisation s transformation and merger with North East London Foundation Trust. Previously he worked for McKinsey & Company advising leading healthcare providers and academic medical centres on strategy, operations, organisational development, and mergers and acquisitions in Europe, the Middle East, and Japan. Attila brings to CPFT a unique combination of experiences as a clinician and transformational manager from both the private and public sectors. 4.3 Appointment of Chairman, Non-Executive Directors and Executive Directors The Council of Governors is responsible for appointing the Chair and Non-Executive Directors of the Foundation Trust. During , the Trust s Chair Anne Campbell retired in September 2012 and was replaced by the Council of Governors Nominations Committee with David Edwards OBE as Chair. During the year, one Non-Executive Director resigned due to work commitments. Another Non-Executive Director s term of office ended in December 2012 and another ended in March The Council of Governors Nominations Committee appointed two new Non-Executive Directors to begin their terms in January 2013 and a further two to begin their terms in April The Chairman, Non-Executive Directors and Chief Executive (with the exception of appointments to that role) are responsible for the appointment of Executive Directors. During the year, one Executive Director resigned in April 2012 and another in May These posts were the Chief Operating Officer and Director of Nursing and the Director of Finance and Performance respectively. The Directors Nominations Committee appointed three substantive Executive Directors. The first was Director of Service Improvement/Chief Information Officer in April A Director of Nursing was appointed in April 2012 but resigned and was replaced in November 2012 with a further substantive Director of Nursing. Three interim Executive Directors were appointed by the Directors Nominations Committee during the year. The first in April 2012, was Interim Chief Operating Officer. The second interim post was the Acting Director of Finance from May to June 2012, where the Deputy Director of Finance acted up and the third, an Interim Director of Finance from July The removal of the Chair and Non-Executive Directors requires the approval of threequarters of the Council of Governors and should be in accordance with the procedures set out in CPFT s constitution. Disclosures of the remuneration paid to the Chair, Non-Executive Directors and senior managers are given in the Remuneration Report on page 54. Page 39

90 Terms of office of members of the Board of Directors Appointed Reappointed Expiry/End of Term of office Anne Campbell Chair December 2005 September 2009 Retired September 2012 David Edwards Chair September N/A September OBE Tom Abell Director of Service Improvement/Chief Information Officer April 2012 N/A N/A Barbara Beal Director of Nursing April 2012 N/A Resigned November 2012 Darren Cattell Interim Director of October 2012 N/A June 2013 Finance Melanie Coombes Director of Nursing November N/A N/A 2012 Ashish Dasgupta Non-Executive Director April 2007 March 2011 June 2013 Chess Denman Medical Director January 2012 N/A N/A Robert Dixon Non-Executive Director October 2007 October 2010 October 2013 Ian Goodyer Non-Executive Director May 2008 N/A Retired December 2012 Terry Holloway Non-Executive Director April 2007 March 2011 Retired March 2013 Lucy O Brien Non-Executive Director January 2006 September 2009 January 2013 (Resigned June 2012) Derek McNally Acting Director of May 2012 N/A June 2012 Finance Barbara McLean Chief Operating Officer and Director of Nursing January 2012 N/A Resigned April 2012 Jenny Raine Director of Finance and Performance September 2010 N/A Resigned May 2012 Mick Simpson Interim Director of Nursing and Chief Operating Officer April 2012 N/A Ceased to be Interim Director of Nursing November Interim Chief Operating Officer to July 2013 Sir Patrick Sissons Non-Executive Director January 2013 N/A January 2016 Julie Spence OBE Non-Executive Director January 2013 N/A January 2016 Keith Spencer Director of People and Business Development June 2008 N/A N/A Page 40

91 Attila Vegh Chief Executive October 2011 N/A N/A 4.4 Register of Interests On appointment, all Directors are asked to declare any interests for inclusion within the Register of Directors Interests. The register is reviewed periodically. There is a standing item on the agenda for each meeting of the Board of Directors and committee meetings to ensure that interests relevant to the meeting are declared. The register is maintained by the Trust Secretary and is available for inspection by members of the public upon request to Trust Secretary at the following address: Trust Secretary, CPFT, Elizabeth House, Fulbourn Hospital, Cambridge CB21 5EF Attendance at Board of Directors Meetings Name Title Attendance out of 12 (unless indicated otherwise) Anne Campbell Chair (Until September 2012) 5 (out of 5) David Edwards Chair (From September 2012) 5 (out of 7) OBE Tom Abell Director of Service Improvement/Chief Information 11 Officer (From April 2012) Darren Cattell Interim Director of Finance (From July 2012) 9 (out of 9) Melanie Coombes Director of Nursing (From November 2012) 5 (out of 5) Ashish Dasgupta Non-Executive Director 12 Robert Dixon Non-Executive Director 11 Ian Goodyer Non-Executive Director (Until December 2012) 8 (out of 9) Terry Holloway Non-Executive Director (Until March 2012) 7 Lucy O Brien Non-Executive (Until June 2012) 3 (out of 3) Caroline Mitchell Turnaround Director (From June to September 2012) 1 (out of 4) Barbara McLean Chief Operating Officer and Director of Nursing (Until 0 (out of 0) April 2012) Derek McNally Acting Director of Finance (From May to June 2012) 2 (out of 2) Jenny Raine Director of Finance and Performance (Until May 1 (out of 1) 2012) Mick Simpson Interim Director of Nursing and Chief Operating 12 Officer from April 2012/Interim Chief Operating Officer from November 2012 Sir Patrick Sissons Non-Executive Director (From January 2013) 2 (out of 3) Julie Spence OBE Non-Executive Director (From January 2012) 1 (out of 3) Keith Spencer Director of People and Business Development 12 Attila Vegh Chief Executive 11 Page 41

92 Meeting dates 25 April 2012, 30 May 2012, 27 June 2012, 25 July 2012, 17 August 2012, 26 September 2012, 31 October 2012, 28 November 2012, 19 December 2012, 30 January 2013, 27 February 2013, 27 March Board of Directors sub-committees The Board has discharged its functions throughout the year through its subcommittees as outlined below. The terms of reference for Board of Directors subcommittees are reviewed annually. 4.5 Audit and Assurance Committee This committee chaired by a Non-Executive Director is responsible for ensuring that an effective system of integrated governance, risk management and internal control is in place to support the achievement of CPFT s strategic objectives. The Audit and Assurance Committee receives and considers reports from both Internal and External Auditors and approves the annual accounts and financial statements for submission to the Board of Directors. The committee is made up entirely of Non-Executive Directors. Ashish Dasgupta will relinquish the chairmanship of the committee at the end of March 2013 and Robert Dixon will step down from membership at the end of March In the new financial year, new Non-Executive Director John Lappin will chair the committee and the other member will be Julie Spence. Name Attendance out of 6 (unless indicated otherwise) Ashish Dasgupta, Chair / Non-Executive Director 6 Robert Dixon, Non-Executive Director 6 Meeting dates 20 April 2012, 20 July 2012, 6 September 2012, 19 December 2012, 14 January 2013, 13 March Business and Risk Committee During the year, the Business and Risk Committee ceased to meet, as it duties were subsumed into the Quality and Performance Committee from July The last meeting of the committee took place on 21 June This committee was chaired by a Non-Executive Director and was responsible for the scrutiny of current and future financial performance, business plans and overseeing governance for the management of all risks. It regularly reviewed the Board Assurance Framework and Risk Register as a way of seeking assurance that risks were being managed effectively. The committee membership consisted of two Non-Executive Directors and the following Executive Directors: Chief Executive, Director of Finance, Chief Operating Officer, Director of Nursing and Director of People and Business Development. The Managing Director of Anglia Support Partnership was an invited attendee. Robert Dixon, Non-Executive Director, was Chair of the Committee. The Director of Service Improvement /Chief Information Officer also attended the committee. Page 42

93 Name Attendance out of 3 (unless indicated otherwise) Robert Dixon, Non-Executive Director/Chair 3 Derek McNally, Interim Director of Finance 1 (out of 2) Barbara Beal, Director of Nursing 0 Lucy O Brien, Non-Executive Director 2 Jenny Raine, Director of Finance and Performance 1 (out of 1) Mick Simpson, Interim Chief Operating Officer 2 Keith Spencer, Director of People and Business Development 3 Attila Vegh, Chief Executive 2 Meeting dates 19 April 2012, 24 May 2012, 21 June Quality and Healthcare Governance Committee During the year, the Quality and Healthcare Governance Committee ceased to meet, as its duties were subsumed into the Quality and Performance Committee from July This committee was chaired by a Non-Executive Director and was responsible for ensuring that the Trust had a proper approach to quality, safety and governance in the areas of clinical and service delivery. It set strategic priorities so that all activities of the Trust contributed to compliance with the Mental Health Act and Mental Capacity Act Regulations, Health and Social Care Act (2008) and CQC Regulations The committee also monitored continuous improvement in patient experience and safeguarded patient safety, ensuring all services were based upon best practice guidance. The committee oversaw the Trust s work programme for meeting all requirements within Essential Standards of Quality and Safety, Information Governance standards, R&D Governance standards, NHSLA Risk Management standards and MHA Code of Practice. The committee membership consisted of two Non-Executive Directors and the following Executive Directors: Chief Executive, Medical Director, Director of Nursing, Chief Operating Officer and Director of People and Business Development. The committee was also attended by the Director of Service Improvement/Chief Information Officer. Name Attendance out of 3 (unless otherwise stated) Terry Holloway, Non-Executive Director/ Chair 2 Barbara Beal, Director of Nursing (from April 2012 to November 2012) 0 Chess Denman, Medical Director 0 Derek McNally, Interim Director of Finance (from May 2012 to June 0 (out of 2) 2012) Lucy O Brien, Non-Executive Director (to June 2012) 2 Jenny Raine, Acting Chief Executive/ Director of Finance (to May 1 (out of 2) 2012) Mick Simpson, Interim Chief Operating Officer (from April 2012) 2 Page 43

94 Keith Spencer, Director of People and Business Development 2 Attila Vegh, Chief Executive 2 Meeting dates 23 April 2012, 25 May 2012, 26 June This committee had a number of sub-groups which covered a range of subject issues, including for example, risk management, safeguarding children, and infection prevention and control. These sub-groups produced an annual plan of activities and provided routine reports into the committee. 4.8 Quality and Performance Committee The Quality and Performance Committee met for the first time on 19 July 2012 and was formed as an amalgamation of the Quality and Healthcare Governance Committee and the Business Risk Committee. The committee is responsible for providing assurance to the Board of Directors through the Quality and Performance governance structure within the Trust, that the organisation is able to meet all expected regulatory and statutory standards of care, expected safety and quality performance standards, and to ensure that strategic and operational risks which may affect the delivery of these are being managed to within acceptable levels. The committee is also responsible for providing assurance to the Board in relation to financial and non-financial performance issues. In particular the committee reviews and advises the Board on in year performance against previously agreed board objectives / targets (monitoring). The committee membership consists of two Non-Executive Directors, one of whom shall be the Chair and the following Executive Directors: Medical Director, Director of Nursing, Director of Service Improvement/Chief Information Officer, Director of Finance, and Chief Operating Officer. Robert Dixon was appointed Chair of the committee. In addition, the committee is also frequently attended by the Chief Executive and the Director of People and Business Development. As the meeting has responsibility linked to the quality agenda, it meets on a monthly basis. Name Attendance out of 8 (unless otherwise stated) Robert Dixon, Non-Executive Director and Chair of Committee 8 Tom Abell, Director of Service Improvement/Chief Information 7 Officer Barbara Beal, Director of Nursing (from April to November 2013) 1 (out of 3) Darren Cattell, Interim Director of Finance (from July 2012) 7 Melanie Coombes, Director of Nursing (from November 2013) 5 (out of 5) Chess Denman, Medical Director 3 Ian Goodyer, Non-Executive Director (to December 2012) 0 (out of 5) Mick Simpson, Interim Chief Operating Officer (from April 2012) 5 Sir Patrick Sissons, Non-Executive Director (from January 2013) 2 (out of 3) Julie Spence OBE, Non-Executive Director (from January 2013) 3 (out of 3) Meeting dates 19 July 2012, 10 September 2012, 17 October 2012, 14 November 2012, 13 December 2012, 14 January 2013, 13 February 2013, 14 March Page 44

95 4.9 Nominations Committee The membership of this committee comprises the Chair and Non-Executive Directors. The committee is advised by the Chief Executive and the Director of People and Business Development and is responsible for the nomination and appointment of Executive Directors Governors Nominations Committee The Governors Nominations Committee, which is a standing committee of the Council of Governors, is responsible for Non-Executive Director (NED) Appointments. This committee comprises one appointed Governor and two elected Governors, and is chaired by the CPFT Chair. The Chief Executive and Director of People and Business Development act as advisors to this committee. The Governors Nominations Committee held four meetings to manage the process of the recruitment of a new Trust Chair and four new Non-Executive Directors and these appointments were made during the course of the year. Annual appraisal of Non-Executive Directors is carried out by the Trust Chair. The senior independent Director appraises the Chair in consultation with Non-Executive Directors and Governors. During discussions relating to the appointment of a new Chair of the Trust, Non-Executive Director Ashish Dasgupta chaired the committee. Three Non-Executive Directors terms of office came to an end during the year and one Non-Executive Director, whose term of office was due to come to an end at the end of March 2013, had their term extended to provide continuity due to their role as Chair of the Audit and Assurance Committee. Attendance at the meetings is given in the table below: Name Attendance out of 4 (unless otherwise stated) Anne Campbell, Chair to September John Cranston, Public Governor 4 Ashish Dasgupta, Non-Executive Director (acting chair during the 2 appointments process for a new Trust Chair) Mike Farmiloe, Public Governor/ Lead Governor 4 Diana Wood, Appointed Governor, University of Cambridge 3 Brenda Hennessy, Appointed Governor, Cambridge University Hospitals 1 NHS Foundation Trust (replaced Diana Wood on the Committee from August 2012) Meeting dates 19 April 2012, 8 May 2012, 11 June 2012, 9 August Remuneration Committee Membership of this committee comprises the Chair and Non-Executive Directors. Details of meeting attendance for this committee is outlined within the Remuneration Report detailed in section 7. Page 45

96 The duties of the Board s Remuneration Committee include Executive Director remuneration and terms of service. It also reviews the structure, size and composition of the Board of Directors, and the identification and nomination of Executive Directors. During the year, the committee recruited a substantive Director of Nursing and Melanie Coombes took up this post in November 2012 and an Interim Director of Finance, with Darren Cattell taking up this role from July Individual objectives are agreed with the Chief Executive for each of the Executive Directors. Annual pay awards are subject to achieving objectives Board and Committee Effectiveness The performance of the Board of Directors is reviewed collectively as part of an independent Board evaluation process. During the past year, this was facilitated by way of an external review of Board Effectiveness carried out by DAC Beachcroft. This report followed a review carried out in May 2012, which consisted of a document review, including agendas and minutes, as well as interviews with Directors and other key staff. A number of recommendations were made as part of the report produced by DAC Beachcroft and the Trust acted on these throughout the year, culminating in a follow-up review in January and February The outcome of this review was that the Board s effectiveness was such that it was ready for de-escalation. The external review carried out by PwC in May 2012 also covered a number of aspects of Board Effectiveness and was aligned with Monitor s Quality Governance Framework. An initial assessment rated the Trust at 16, on a 20-point scale where perfect adherence to the Framework was represented by a score of zero and the worst score was 20. The outcome of a follow-up reassessment of the Trust in January and February 2013 was that the Trust s score had improved to 3.5, below the score of 4 which was required for de-escalation. The Board committees undertake annual reviews of their own effectiveness. Page 46

97 5. MEMBERSHIP 5.1 CPFT membership The membership of CPFT is split between three constituencies: public, patients and staff. Any person aged 16 or over who lives within the Trust s membership area is eligible for public membership. 5.2 Public membership Subject to the exclusions for membership set out in the constitution: membership is open to everyone who lives in the electoral areas of Cambridgeshire and who is 16 years and older membership is open to everyone who lives in the electoral area of Peterborough and who is 16 years and older people over the age of 16 living in the rest of England 5.3 Patient membership An individual who has been a service user of CPFT since its inception in April 2002 (ie, all open or closed referrals) is eligible to be a member of the Patients Constituency. An individual who is a carer of a service user is eligible to be a carer member. There are four classes within the Patients Constituency: for service users living in Cambridgeshire for service users living in Peterborough for service users living in the rest of England for carers living in Cambridgeshire, Peterborough and the rest of England 5.4 Staff membership All staff who have contract of employment with CPFT are automatically members unless they choose to opt out. An individual who is employed by CPFT under a contract of employment with CPFT may become a member provided: they are employed by CPFT under a contract of employment, which has no fixed term or has a fixed term of at least 12 months, or they are continuously employed by CPFT under a contract of employment for at least 12 months In addition, individuals who are seconded to CPFT and exercise paid functions for the purpose of CPFT, may become a member of the staff constituency, provided they have exercised these functions continuously for a period of at least 12 months. 5.5 Membership numbers As at 31 March 2013 CPFT had 11,374 members: 1,279 patient, 7,860 public and 2235 staff members. CPFT maintains communications with its membership through public meetings of the Council of Governors, CPFT website, newsletters and alerts. Member events provide an opportunity for members to meet with Governors as well as staff. 5.6 Membership strategy CPFT s membership strategy set our vision for a representative, active and engaged membership. It outlines a strategy for membership development for the next three years and the priorities for action that will help the Trust ensure that it has a representative and engaged membership. Page 47

98 The membership strategy as set out in the Trust Three-Year Strategy and Annual Plan was to increase the total membership to 12,009 members by 31 March This target has been exceeded as a result of recruitment activities and through direct mailings to patients. A number of events to engage with members and recruit new ones were held during the year. Joint membership events with Cambridge University Hospitals NHS Foundation Trust have continued this year, centred on the Medicine for Members lectures, with lectures this year entitled:, Autism a story of hide and seek focused on autism in adults and was attended by more than 50 CPFT members. Two events were held with the Manic Depression Fellowship (MDF) in Cambridge and Peterborough, with more than 100 people attending both events. A talk was held in partnership with the Cambridge Psychiatry Society focusing on self harm. The last event on the financial year was held in March with a talk on anger management that had an engaged audience. The Trust s Annual Public Meeting was held in September 2012 at Peterborough United Football club and was well attended by members, Governors, and staff. Members who wish to contact Governors or Directors can do so by contacting the Membership Office: foundationtrust@cpft.nhs.uk / rebecca.moore@cpft.nhs.uk Telephone: Freephone: By post: Trust Secretary, CPFT Headquarters, Elizabeth House, Fulbourn Hospital, Cambridge, CB21 5EF Via the website: Face to face: Members and the public can attend events throughout the year and meet Governors and Directors. Opportunities for interaction are the Council of Governors meetings, the Annual Public Meeting and member talks. Details of these meetings are available on the Trust website or from the Membership Office, details above. Page 48

99 6. Public interest 6.1 Consultation with and involvement of employees CPFT maintains a Staff Consultative Forum to provide a formal and frequent mechanism for consultation, negotiation and communication with recognised trade unions. In addition we maintain specific forums for various communities of interest including medical staff. We maintain a Wider Leadership Team meeting for our top 100 leaders that meets for a half day every two months. Specific developments and changes across CPFT are consulted on with the relevant staff. The Chief Executive holds bi-yearly Town Hall Events where all staff attend an interactive two-hour discussion session on corporate objectives. A staff Guiding Coalition Forum has been established that involves 80 staff in progressing the Trust s agenda. It meets bi-monthly with work being completed between meetings. There is also a monthly online Webex session (live intranet discussion forum) where staff can engage with the Executive Team on a range of topical issues. A weekly staff newsletter is sent out to all staff along with regular communication direct from the Chief Executive. An updated intranet provides staff with up-to-date information on Trust performance. 6.2 Equal opportunities, disabled employees CPFT has a range of policies and schemes to promote equality and diversity across all aspects of our services and throughout our employment practice. This includes an Equality and Diversity Policy and Dignity at Work policies and procedures. The Trust has an Equality and Diversity officer in post leading on this agenda. Two staff forums have been established. These are the Ethnic Minority Network (EMN) and the Lesbian, Gay, Bisexual and Transexual Network (LGBT). The Trust has implemented the Equality Delivery System, which resulted in completing a self-assessment. This has identified four key objectives for the coming year. The Trust continues to maintain the disability symbol and is recognised as a Mindful Employer. We have worked with our occupational health provider to better address the health needs and support of all staff including those with a disability. As part of our overall recovery programme, we have an employment initiative to establish a robust framework for providing opportunities for people with mental health problems in education, training and employment and to support employers and education providers to understand mental health in the workplace. A new staff access to services pathway has been developed and is moving forward for implementation. 6.3 Health, safety and occupational health We continue to be committed to providing safe environments in which staff can work and service users and carers can access services safely. This work is overseen by our Patient Safety and Risk Management Committee which meets regularly and Page 49

100 includes safety representatives, managers and Serco, which provide us with a range of support services in regard to health and safety. The CPFT Health and Wellbeing Strategy aims to embed a positive health and wellbeing culture for all staff and that this is underpinned in the Trust s policies and procedures, including through appraisal, supervision and learning and development programmes. It aims to: Reduce sickness absence by improving the services available to staff for their mental health Reduce pressure felt by staff and effectively manage stress levels Reduce the number incidents of staff affected by violence and bullying/harassment via a Zero-Tolerance Policy Provide better access to health and wellbeing activities and facilities Our occupational health service is provided by Serco, who we have regular contact with. It has confirmed that it is awaiting the outcome of its SEQOHS accreditation (Safe Effective Quality Occupational Health Services). The Trust has submitted its application for the accreditation process for ashawd (local SHA accreditation scheme for health and wellbeing at work), which gives a clear framework for good practice. Once CPFT has received ashawd accreditation, planning will start for achieving ashawd accreditation which is linked to the IIP award. The effectiveness of the health and wellbeing initiatives is monitored and measured via the annual Staff Survey and through engagement measured by the bi-monthly pop-up Pulse Surveys. In addition key workforce KPIs such as turnover and sickness are reported to the Trust Board quarterly and executive team monthly. Promotion of health and well being is through dedicated intranet pages, Staff Matters, which contains several pages of information for health and wellbeing. 6.4 Counter-fraud policies We have a policy in place whereby any member of staff who suspects fraud or corruption is taking place has access to the relevant contact details. CPFT has a nominated Local Counter-Fraud specialist who works on behalf of the Board to ensure staff are trained and are aware of the seriousness and importance of this issue to CPFT. Any concerns are reported to the Local Counter-Fraud Specialist and the Executive Director of Finance where upon further investigations take place to look into all concerns raised. The Local Counter-Fraud Specialist formally reports twice per annum into the Audit and Assurance Committee, although they will make the committee aware of any significant issues at other times. 6.7 Information on NHS sickness data We have worked hard to continue our positive improvement in this workforce indicator. The year end average position of 3.88% compares favourably to the target of 4.35% although there has been significant fluctuations throughout the year with some months exceeding this target and others falling well below. This result has Page 50

101 been achieved by active sickness case management and support to staff for the main indicators of absence and where there has been a significant rise in sickness is specific areas, proactive work is taken to address this. Data is being fully validated to ensure reporting accuracy. 6.8 Cost statement The Trust has complied with the cost allocation and charging requirements set out in HM Treasury and Office of Public Sector Information guidance. 6.9 Compliance with the NHS Foundation Trust Code of Governance The Board of Directors and the Board of Governors are committed to the principles of good corporate governance as detailed in the NHS Foundation Trust Code of Governance. The Trust Secretary reviews CPFT s compliance with the code throughout the year and as a result CPFT considers that overall it complies with the main and supporting principles outlined within the Code of Governance. This includes the issue of whether or not all of the Non-Executive Directors are independent in character and judgement in accordance with code provision A.3.1. Notwithstanding the relationship with the University of Cambridge, the Board of Directors considered that Professor Ian Goodyer, brought a significant wealth of expertise in academic research and, through being independent of CPFT s management, was able to provide an objective, informed and balanced opinion on these and other matters to the Board of Directors. In addition, Professor Sir Patrick Sissons, who joined the Trust as a Non-Executive Director in January 2013, has had a longstanding involvement with the University of Cambridge, having recently retired as Regius Professor of Physic and Head of the University School of Clinical Medicine. Sir Patrick s extensive and senior experience in the fields of education and research bring a huge amount of strength to the knowledge of the Board, and his extensive understanding of the emerging Academic Page 51

102 Health Science Network structure and the existing Academic Health Science Centre (Cambridge University Health Partners), of which he was a Director until his retirement from the post of Regius Professor of Physic, brings a skill mix that the Trust values extremely highly. Sir Patrick is able to bring judgement and balance to his contributions both at the Board and to the work of the Trust. The Board has therefore determined that all of the Non-Executive Directors are independent in character and judgement. In relation to the more detailed provisions of the Code of Governance, the Trust is either compliance with the provisions or in the process of taking action to ensure compliance, with the following exceptions: A.3.2 At least half of the Board of Directors, (excluding the Chairman) are not independent Non-Executive Directors. At 31 March 2013 the Trust has seven Executive Directors and five independent Non-Executive Directors. Looking ahead to , the Trust will potentially have eight Executive Directors, with the addition of a Director of Service Integration, and will have six independent Non-Executive Directors until the end of June 2013, at which point the number will revert to five with the retirement of Ashish Dasgupta. The Trust had undergone a large-scale turnover of Directors throughout the past year and the Board is of the opinion that extra Executive Director capacity is essential, coupled with the presence of high-quality independent Non-Executive Director input. The strength of independent Non- Executive Director input is such that the Board is confident that there will be effective constructive challenge and that Executive Directors will be held to account not only by Non-Executive Directors but also by one another. A.3.5 The Council of Governors contains two Governors who are also Directors of other NHS Foundation Trusts. Appointed Governor Brenda Hennessy, is a Director of Cambridge University Hospitals NHS Foundation Trust (CUH). The relationship between CPFT and CUH is crucial, not only in terms of the symbiosis as neighbouring mental, community health and acute Trusts, but also as partners in Cambridge University Health Partners. For the same reason, the Board is content that the position of Advisor to the Council of Governors of CUH, fulfilled by Chess Denman is also appropriate. Appointed Governor Chris Wilkinson is Director of Nursing at Peterborough and Stamford NHS Foundation Trust. Again the symbiotic relationship between the mental, community health and acute Trusts both is crucial and, as the acute Trust for the north of CPFT s catchment area, the Board is content that this relationship is appropriate Information on serious incidents (SIs) involving data loss or confidentiality breach In the Trust had three serious incidents involving data loss or confidentiality breach. Of the three reported incidents, only one met the criteria for reporting to the Information Commissioner s Office Statement on the NHS Constitution The Trust has regard to the NHS Constitution in all of its operations, and is particularly robust in its safeguarding of the rights of patients and staff. Page 52

103 Remuneration Report The following information is required by section 156 (1) of the Health and Social Care Act 2012, which amended paragraph 26 of Schedule 7 to the NHS Act 2006, and is not subject to audit: Information on the corporation s policy on pay and on the work of the committee established under paragraph 18(2) of Schedule7 to the NHS Act 2006, and such other procedures as the corporation has on pay; and Information on the remuneration of the directors and on the expenses of the governors and directors. Where a requirement here is duplicated by a requirement below which is subject to audit, the information need only be disclosed once and be subject to audit. The remuneration report in appendix A and B on pages 56 and 57 show information on salary, pensions and allowances of the Executive and Non-Executive Directors and this information has been subject to audit by PricewaterhouseCoopers LLP. No other element of this Remuneration Report has been subject to audit review. 7.1 Remuneration Committee The Remuneration Committee was chaired by Trust Chairman Anne Campbell until August 2012, at which point she was replaced by the new Chairman David Edwards. The committee meets at least twice per year to agree the remuneration and main terms of service of the Chief Executive, Executive Directors of the Trust and any other staff groups not subject to national terms and conditions of service. This includes: All aspects of salary (including any performance-related element/bonuses and cost of living increases) Provision of other benefits including pensions and cars Any arrangements for termination of employment and other contractual terms The committee also approves the objectives of the members of the Executive Team and monitors and evaluates the performance of individual directors on at least an annual basis. Membership of the committee The committee consists of four Non-Executive Directors, one of whom should be the Chair of the Trust. Members are: Anne Campbell, Chair (until August 2012) David Edwards (from September 2012) Terry Holloway, Non-Executive Director Lucy O Brien, Non-Executive Director (until June 2012) Ashish Dasgupta, Non-Executive Director Robert Dixon, Non Executive Director (from July 2012) Other attendees may be co-opted from time to time in accordance with the agenda items. During the course of the committee was supported in its work by: Attila Vegh, Chief Executive Keith Spencer, Director of People and Business Development Page 53

104 Attendance Attendance at committee meetings Name Title Attendance out of 3 (unless otherwise stated) Anne Campbell Chair (until August David Edwards Chair (from September 2012) 2 Terry Holloway Non Executive Director 3 Lucy O Brien Non Executive Director (until June 2012) 1 Robert Dixon Non Executive Director (from July 2012) 2 Ashish Dasgupta Non Executive Director 3 Meeting dates: 10 April 2012, 13 November 2012, 17 December Remuneration and performance conditions To determine Board level salary the Remuneration Committee may use one or more of the following: Benchmarking data surveyed amongst the Trust s peer group including the Foundation Trust Network National and regional surveys of NHS chief executives and executive directors remuneration Reviews the remuneration of advertised executive director roles across the NHS and wider community Other than for the Medical Director, amendments to annual salary are decided by the Remuneration Committee on the basis of the size and complexity of job portfolio. Annual salary is inclusive other payments such as bonus, overtime, long hours, oncall, standby, etc, do not feature in Executive Directors remuneration. The Medical Director s salary is in accordance with the national terms and conditions of the service consultant contract Cost-of-living increases for Directors are linked to the Agenda for Change terms of employment which apply to all Trust staff. The annualised banded remuneration of the highest-paid director in the Trust as at 31 March 2012 was 195, ,000. This was 7.1 times the median remuneration of the workforce, which was 27,625. In , no employees ( , nil) received remuneration in excess of the highest-paid director. Remuneration ranged from 13,903 to 197,997. Total remuneration includes salary, non-consolidated performance-related pay, benefits-in kind as well as severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. 7.3 Duration of contracts, notice periods and termination payments Page 54

105 Executive directors are appointed to permanent contracts, subject to six months notice of termination by either party. Date of the contract, the unexpired term, and details of the notice period are as follows: Executive Director Date in Post Unexpired Term Notice Dr Attila Vegh 31/10/2011 Permanent Six Months Ms Jenny Raine Director of Finance and Performance 01/12/2006 Left May 2012 Six Months Dr Chess Denman - Medical Director 01/01/2012 Permanent Six Months Mr Tom Abell Director of service Improvement/Chief Information Officer Mr Mick Simpson Interim Chief Operating Officer Barbara McLean Director of Nursing and Chief Operating Officer Mrs Melanie Coombes Director of Nursing Mr Keith Spencer Director of People and Business Development 01/04/2012 Permanent Six Months 16/04/2012 Acting Up Three Months 09/01/12 Fixed Term. Left April 2012 Six Months 05/11/2012 Permanent Six Months 01/01/2007 Permanent Six Months Derek McNally Acting Director of Finance and Performance 01/09/2010 Acting up from May 2012 to June 2012 Three Months There are no special contractual compensation provisions for the early termination of Executive Directors contracts. Early termination by reason of redundancy is subject to the normal provisions of the Agenda for Change: NHS Terms and Conditions of Service Handbook (Section 16); or, for those above the minimum retirement age, early termination by reason of redundancy or in the interests of the efficiency of the service is in accordance with the NHS Pension Scheme. Employees above the minimum retirement age who themselves request termination by reason of early retirement are subject to the normal provisions of the NHS Pension Scheme. Dr Attila Vegh Chief Executive David Edwards OBE Chairman Dated: 24 May 2013 Page 55

106 Page 56

107 A) Remuneration Year ending 31 March 2013 Year ending 31 March 2012 Name and Title Salary (bands of 5000) 000 Other Remuneration (bands of 5000) 000 Benefits in Kind Rounded to the nearest 100 Performancerelated bonuses (bands of 5000) 000 Total Salary Other Remuneration (bands of 5000) 000 (bands of 5000) 000 (bands of 5000) 000 Benefits in Kind Rounded to the nearest 100 Performancerelated bonuses (bands of 5000) 000 Totals (bands of 5000) 000 Non-Executive Directors Anne Campbell (Non - Executive Chairman) Note David Edwards - (Non - Executive Chairman) Note Lucy O'Brien (Non - Executive Director) Note Ashish Dasgupta (Non - Executive Director) Terry Holloway (Non - Executive Director) Robert Dixon (Non - Executive Director) Ian Goodyer (Non - Executive Director) Note Sir Patrick Sissons (Non - Executive Director) Note Julie Spense OBE (Non - Executive Director) Note Executive Directors Dr Attila Vegh (Chief Executive) Jenny Raine (Chief Executive (acting)) Note Dr Chess Denman (Medical Director) Barbera McLean (Chief Operating Officer) Note Keith Spencer (Director of Business Development) , Jenny Raine (Director of Finance and Performance) Note Derek McNally (Director of Finance and Performance (Acting)) Note Tom Abell (Director of Service Improvement and Chief Information Officer) Note Melanie Coombes (Director of Nursing) Note , Mick Simpson (Chief Operating Officer) Note Darren Cattell (Director of Finance) Note Note 1 - Resigned September 2012 Note 8 - Resigned April 2012 Note 2 - Apponted September 2012 Note 9 - Resigned April 2012 Note 3 - Resigned June 2012 Note 10 - Acted up from April to June 2012 Note 4 - Resigned December 2012 Note 11 - Appointed April 2012 Note 5 - Appointed January 2013 Note 12 - Appointed November 2012 Note 6 - Appointed January 2013 Note 13 - Appointed April 2012 Note 7 - Resigned April 2012 Note 14 - Appointed July 2012 under a contract for services with Mill Street Consultancy Limited Page 57

108 B) Pension Benefits Name and title Real increase/ (decrease) in pension at age 60 Real increase/ (decrease) in lump sum at age 60 Real increase/ (decrease) in CETV at age 60 Total accrued pension at age 60 at 31 March 2013 Lump sum at aged 60 related to accrued pension at 31 March 2013 Cash Equivalent Transfer Value at 31 March 2013 (bands of 2500) 000 (bands of 2,500) 000 (bands of 2,500) 000 (bands of 5000) 000 (bands of 5000) Dr Attila Vegh (Chief Executive) Miss Jenny Raine (Director of Finance) - Note 1 N/A N/A N/A N/A N/A N/A Dr Chess Denman (Medical Director) Barbera McLean (Chief Operating Officer) Note 2 N/A N/A N/A N/A N/A N/A Mr Keith Spencer (Director of Business Development) (2.5) (2.5) Mr D McNally (Director of Finance and Performance (Acting)) Note 3 N/A N/A N/A N/A N/A N/A Mr Tom Abell (Director of Service Improvement and Chief Information Officer) Note 4 N/A N/A N/A Mrs Melanie Coombes (Director of Nursing) Note 5 N/A N/A N/A Mr Mick Simpson (Chief Operating Officer) Note 6 N/A N/A N/A Mr Darren Cattell (Interim Director of Finance) Note 7 N/A N/A N/A N/A N/A N/A Notes Note 1 - Resigned April 2012 Note 6 - Appointed April 2012 Note 2 - Resigned April 2012 Note 7 - Appointed June 2012 under a Contract for Services with Mill Street Consultancy Limited Note 3 - Acted up April 2012 to June 2012 Note 4 - Appointed April 2012 Note 5 - Appointed November 2012 N/A - The NHS Pension Scheme only provides actuarial valuations of pensions at the year end. It s not therefore possible to calculate figures for directors who are appointed or resign mid-year. As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members. 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. Page 58 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.

109 QUALITY REPORT TO BE INSERTED HERE Page 59

110 9. Staff Survey Report 9.1 Summary of performance results from the national NHS staff survey Statement of approach to staff engagement and feedback arrangements in place and key priorities and targets We have a number of key mechanisms to engage with our workforce. These include a weekly staff news letter sent directly to all staff, a newly developed intranet, which provides direct information to staff on the performance of the Trust, and a direct communication route for staff to the Chief Executive via a regular blog. The Chief Executive holds bi-yearly Town Hall Events where all staff attend an interactive two-hour discussion session on Trust-wide issues objectives. In addition, a bi-monthly staff Guiding Coalition Forum has been established which involves 80 staff in progressing and feeding back upon the Trust s agenda. There is also a monthly Webex session where staff can talk directly online with the Executive Team on a range of topical issues. Feedback from staff is also collected bi-monthly through pop-up Pulse surveys. The results from this are fed directly into the trust performance dashboard. The Executive Team also undertake a programme of back-to-the-floor visits which ensure that every team has at least one visit per year from a member of the Executive Team We regularly meet with recognised trade union representatives through CPFT s Staff Consultative Forum (SCF). The discussions include finances, service developments and performance along with other key issues impacting on staff. We undertake focussed discussions and consultations with staff representatives on specific issues such as organisational change. The trade unions have been consulted over the last year on a number of major transformation consultations. All employment related polices are developed in liaison with staff-side colleagues, and discussed and where relevant ratified / agreed at the bi-monthly SCF and a newly established Policy Forum. Informal discussions outside of the SCF also take place between staff-side colleagues, HR and management. The 2012 Annual Staff Survey was completed by 1185 members of staff between October December 2011, a sample of which (441) was used by the Department of Health to report and directly compare to other mental health and learning disability organisations. These findings indicate a worse than average score for overall staff engagement. The areas the Trust performed well in and are the weakest areas are detailed overleaf. The Trust will undertake the following actions in response to the survey findings: Undertake a thorough analysis of questions as well as key findings. Page 60

111 Complete analysis for divisions, occupational groups and demographical profile of respondents. Review against current objectives and priorities already in place as part of the Trust s Strategic Objectives. Develop a communications plan, around the results and engaging with the Trust in developing an action plan to improve staff experience. Achieve feedback from the Executive Team around priority focus going forward. Create an action plan involving representatives from the whole organisation. Focus on staff engagement. Develop workforce strategy in liaison with staff. Top scores The below chart illustrates CPFT s top five rankings: Key Finding Description % of staff having equality and diversity training in last 12 months % of staff receiving health and safety training in last 12 months 7 % of staff appraised in last 12 months 4 Effective team working 18 Threshold 2012 score Higher the better 77% 59% Higher the better 84% 73% Higher the better 91% 87% Higher the better % of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months Lower the better 30% 30% Bottom scores Where CPFT have not scored as high can be seen on the below chart. These are CPFT s bottom five ranking scores: National Average for MH & LD Trusts (2012) Key Finding Description Staff recommendation of the Trust as a place to work of receive treatment % of staff suffering work-related stress in last 12 months Fairness and effectiveness of incident reporting procedures Threshold 2012 score National Average for MH and LD Trusts (2012) Higher the better Lower the better 52% 41% Higher the better Page 61

112 1 % of staff feeling satisfied with the quality of work and patient care they are able to deliver 3 Work Pressure felt by staff Higher the better 68% 78% Lower the better Regulatory report 10.1 Monitor s regulatory ratings Once authorised, all NHS Foundation Trusts are subject to their terms of authorisation a detailed set of requirements they must operate within. All of the rules and regulations are set out in Monitor s Compliance Framework, including how Monitor will intervene if an NHS Foundation Trust breaches, or risks breaching, its terms of authorisation. Monitor held a consultation on its draft Risk Assessment Framework, which during the year will replace the Compliance Framework. Each year, all NHS Foundation Trusts are required to submit their rolling three-year plans to Monitor. Once Monitor has analysed these plans, it assigns two risk ratings to each NHS Foundation Trust. The risk ratings indicate Monitor s view on whether or not the NHS Foundation Trust is at risk of breaching its terms of authorisation. The categories of risk rating are: Governance: is CPFT being sufficiently well managed to deliver high-quality services, is it meeting national targets and core standards set by the Government, and is it delivering all of the services it has a legal obligation to provide (under contract with its commissioners). Finance: whether or not Monitor has any concerns about the financial performance of a Foundation Trust During the course of the subsequent 12 months Monitor reviews each NHS Foundation Trust s performance against its annual plan. All risk ratings are updated quarterly. At the beginning of the financial year the Trust submitted an Annual Plan to Monitor which delivered a planned Financial Risk Rating of two for the year taking into account the significant challenges faced by the organisation in regard to CQC compliance and the Trust being found in significant breach of its authorisation as a Foundation Trust in quarter 4 of During the year the Trust implemented an extensive turnaround programme focused on quality, governance and the financial position of the Trust in order to resolve the regulatory concerns. Following the implementation of this turnaround programme the CQC announced that all outstanding concerns were resolved in January 2013 and Monitor de-escalated the Trust in March Page 62

113 Financial risk rating Governance risk rating Financial risk rating Governance risk rating Annual Plan Q Q Q Q Amber-Red Amber-Red Amber-Red Amber-Red Red Annual Plan Q1 Q2 Q3 Q Red Red Red Red Green 11. Equality and diversity report 1. Introduction Cambridgeshire and Peterborough NHS Foundation Trust is committed to providing an environment where all staff, service users and carers enjoy equality of opportunity. The Trust understands the importance of being compliant with the various pieces of equality legislation and acknowledges the benefits and contribution that managing equality and diversity makes to the achievement of its business objectives in the areas of employment, service planning and service delivery. Promoting equality, embracing diversity and ensuring full inclusion for people who use our services is central to the vision and values of the Trust. Promoting equal opportunities, preventing discrimination and valuing diversity are fundamental to building strong communities and services. The Trust is committed to: - Developing policies, processes, procedures, practices and behaviours which challenges all forms of discrimination and promotes equality of opportunity at all levels - Creating an organisation that harnesses the different perspectives and skills of all staff and provides a working environment free from discrimination, harassment or victimisation In being able to meet its business objectives and duties the Trust adopted the national Equality Delivery System (EDS) in 2011 to drive this area of work. The purpose of the EDS is to ensure that services promote the independence and well being of staff, service users and carers and help them to maximise their potential, offer them protection when they need it and support their rights and choices. Page 63

114 2. Legislative context Equality Act The Equality Act (2010) places an equality duty on public bodies such as the Trust which encourages us to engage with the diverse communities affected by our activities to ensure that policies and services are appropriate and accessible to all and meet the different needs of the communities and people we serve. The equality duty consists of a general duty with three main aims. It requires the Trust to have due regard to the need to: 1. Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the act 2. Advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it. 3. Foster good relations between persons who share a relevant protected characteristic and persons who do not share it. Having due regard means that we must take account of these three aims as part of our decision making processes; in how we act as an employer, how we develop, evaluate and review policy; how we design, deliver and evaluate services; and how we commission and buy services from others. The general duty is also underpinned by a number of specific duties which include the need for us to: Set specific, measurable equality objectives; Analyse the effect of our policies and practices on equality and consider how they further the equality aims; Publish sufficient information to demonstrate we have complied with the general equality duty on an annual basis. 2. Across the Trust There is a plethora of work being undertaken across the Trust to help develop a more inclusive and diverse organisation. Work is undertaken by the following: Community development work o The Community Development Worker provides valuable support to staff working with black and minority ethnic (BME) service users while working within communities to raise the awareness of mental health issues. Chaplaincy work o The Chaplaincy team has been doing great work in supporting both staff and patients across the Trust. The Trust recently appointed Ros Lane as a Chaplain at the Cavell Centre alongside Mary Hanna, and John Nicholson in Fulbourn Staff Ethnic Minority Network o In 2009 the black and minority ethnic (BME) staff network was re-launched and re-branded as the Ethnic Minority Network (EMN). A new EMN planning committee was also formed which meets once a month. Page 64

115 o The network organised a number of initiatives and events to celebrate Black History Month in Furthermore, the network provides support to staff across the Trust and also works on projects and initiatives that can promote or further equality at Trust. Lesbian, Gay, Bisexual and Trans (LGBT) staff network o As a result of feedback from the Stonewall Workforce Equality Index it was decided that setting up an LGBT group might enable the Trust to develop its profile as an LGBT friendly workplace. Such a group would act as a networking medium for staff across the organisation but also as a working group that looks at possible awareness raising initiatives across the organisation. 3. The Equality Delivery System and Equality Objectives Equality Delivery System (EDS) Throughout 2011, majority of NHS organisations have been undertaking research, engagement, collection of evidence and other activities to feed into the development of equality objectives for Under the Equality Act 2010, every public sector organisation has a duty to promote equality in employment and service delivery. One of the specific duties was to publish equality objectives by April The Equality Delivery System is a framework that has been developed to support the implementation of equality objectives. As a national framework it consists of the following four goals: 1. Better health outcomes 2. Improved patient access and experience 3. Empowered, engaged and supported staff 4. Inclusive leadership at all levels Each of the four goals is accompanied by a number of outcomes. It is against these outcomes that organisations are graded against. Red = Undeveloped Amber = Developing Green = Achieving Purple = Excelling A core part of the EDS is engagement with stakeholders, service users, staff, staff-side, community groups and local government. It is people from these local interest groups that will contribute to the grading process and decide how well the Trust is performing. On 29 January 2013 CPFT s EDS progress was graded by local interest groups in a joint event with other NHS organisation in the area. The event was opened by Alan Mack (Director of Corporate Development and Performance) and organisations in attendance included Cambridgeshire LINK, Crossroads Care Cambridgeshire, SexYouality, and Norfolk LINK. Page 65

116 These grades will be published nationally by the Department of Health and also taken into account by the Care Quality Commission (CQC). Equality Objectives The EDS grading process has allowed CPFT to undertake a thorough review of its practices and processes. Through the collection of evidence on a range of fronts including service delivery and employment, a few key themes have emerged that have formed 5 key objectives forming the foundation of the work around equality and diversity. Work on these will continue until April 2016 and will allow for continuous improvement of our systems and process in relation to equality and diversity. Alongside these continuous improvement objectives there will be four yearly objectives that will aim to implement or develop certain aspects of equality and diversity at the Trust. The following diagram highlights the structure of these objectives: Page 66

117 Raise the profile of E&D at CPFT by Organising series of communications and events throughout 2013/2014. (Beginning during the w/c 13 th May in line with NHS Equality, human rights and inclusion week) Embed equality and diversity throughout the organisation through the establishment of a network of diversity champions across the new structure Achieve top 200 status in Stonewalls LGBT Friendly Employers index by April 2014 (2010 position 350) Improve the representation of BME staff in Leadership positions (EMN to undertake a piece of work to research barriers to BME Leadership) priorities EDS and Equality Objectives Objective 1 (Relevant to all EDS goals) Objective 2 (Relevant for EDS Goals 2, 3 and 4) Objective 3 (EDS Goal 3 and 4) Objective 4 (EDS Goals 1 and 2) Objective 5 (EDS Goal 3) Develop a central resource to provide detailed equality data on patients, service users, communities served and staff to inform the design and delivery of an inclusive and equitable environment for all. Formulate an Engagement plan for Service users, employees and relevant stakeholders belonging to protected characteristic s Review and develop an equality and diversity training strategy that supports and underpins other relevant training. Continuously review and Improve translation and communicatio n services Support and establish a range of staff networks for protected characteristic s There is a lot of positive work across the Trust that supports equality and provides a solid platform for further work. The Trust has a long way to go to fully understand and meet the needs of all the protected characteristics under the Equality Act 2010 (as with most organisations) but it is well placed to meet the challenge. Page 67

118 12. Statement of Chief Executive s responsibilities as the Accounting Officer of Cambridgeshire and Peterborough NHS Foundation Trust The NHS Act 2006 states that the Chief Executive is the accounting officer of the NHS Foundation Trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer memorandum issued by Monitor. Under the NHS Act 2006, Monitor has directed Cambridgeshire and Peterborough NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Cambridgeshire and Peterborough NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; make judgements and estimates on a reasonable basis; state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; and prepare the financial statements on a going concern basis. The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor s NHS Foundation Trust Accounting Officer Memorandum. Signed. Chief Executive Date: 24 May 2013 Page 68

119 ANNUAL GOVERNANCE STATEMENT TO GO HERE Page 69

120 PAGES TO FOLLOW INSERT FINAL ACCOUNTS Page 70

121 Agenda Item: 8 BOARD OF DIRECTORS MEETING REPORT Subject: Annual Governance Statement FY13 Date: 16 May 2013 Author: Deputy Director Corporate Finance Lead Director: Chief Executive Officer Executive Summary: The attached statements fairly reflects the Trusts Governance journey over the last 12 months and is balanced and realistic. Recommendations: The Board is asked to approve the Statement. The Board is asked to approve the Chief Executive to sign the statement to evidence the Boards approval. Relevant Strategic Priorities (please mark in bold) Our services will be recognised as world class We will develop service plans that achieve financial stability We will develop our built environment and technology infrastructure to deliver our vision We will deliver care through engaged and empowered people We will develop strong relationships based on trust and mutual respect with key stakeholders Links to BAF/Corporate Risk Register Details of additional risks associated with this paper (may include CQC Essential standards, NHSLA, NHS Constitution) Financial implications/impact Legal implications/impact Partnership working and public engagement implications/impact None No additional Risks None None None

122 Committees/groups where this item has been presented before Has a QIA been completed? If yes provide brief details Audit and Assurance Committee Not applicable 1 PURPOSE This report sets out my Annual Governance Statement for FY13 for the Committee s review and approval. 2 BACKGROUND The Trust is required to complete an annual governance statement each year. The statement is based upon the model annual governance statement from the Annual Reporting Manual and has been adapted to reflect the Trust circumstances. 3 PROCESS The statement was drafted in late April and has been circulated to Committee members, Internal and External auditors and the Trust Chair for comment. I am satisfied that this final version addresses the vast majority of comments raised by all parties who have reviewed it. I would however point out that most of the structure is heavily prescribed and therefore it has not been possible to accommodate every comment, however I do think the revised statement is balanced and reflects the gravity of the position of the Trust over the last 18 months and the significant changes made to address those issues. The final statement is attached at Appendix 1. 6 CONCLUSION The Board is asked to approve the Statement. The Board is asked to approve the Chief Executive to sign the statement to evidence the Boards approval.

123 12. Annual Governance Statement Overview of the year This has been a further difficult and challenging year for the Trust. The Trust reported in last years Annual Governance Statement that in March 2012, Monitor s Compliance Board Committee took the decision to declare that the Trust was in significant breach of Authorisation, namely its governance duty including; Failure to comply with CQC registration standards Time taken to address concerns raised by the CQC Lack of Board risk management, leadership and scrutiny and Board awareness of quality governance During the course of this year the Trust has commissioned external reviews of Board leadership and Governance functions. The reviews highlighted a significant numbers of recommendations and the Trust produced comprehensive action plans to deliver on the recommendations. A number of significant changes have been made within the Trust including the appointment of a new Chairman and four new Non-Executive Directors to strengthen the Board provide leadership to the Governance and Risk management functions. Further changes which we have made to strengthen our Governance arrangements are detailed within this report. The Trust also commissioned follow up independent reviews during the latter part of this year which were reported to Monitor as evidence of the completion of the required improvements and I am happy to report that as a result of the significant changes made, on 20 March 2013, Monitor confirmed that the Trust was no longer in breach of the terms of its authorisation. 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 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 on-going process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Cambridgeshire and Peterborough Page 1

124 NHS Foundation Trust (the 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 reviewed and improved upon within the Trust for the year ended 31 March 2013, and is now in place up to the date of approval of the annual report and accounts. Capacity to handle risk During the year the operational management structure within the Trust has undergone a major revision, moving from five to three clinical divisions. In innovative practice, each Division was asked to demonstrate their understanding of clinical services, quality/corporate governance, risk management and finances as part of an authorisation process similar to that applied by our Regulator, Monitor. Leadership within the divisions were also required to demonstrate a sound grasp of the key overarching risks for the Trust, and how these related to their own divisions. Within divisions, individual teams are expected to identify and understand local risks and ensure that these feed into the overall divisional risk registers. Divisional risk registers receive regular monthly scrutiny and challenge through the new Trust governance structure, notably at a corporate level at the Performance and Risk Executive where divisions report their key issues of risk, and the Executive Directors hold divisional leadership to account for their management and mitigation. This forum is also an opportunity for key divisional issues posing a risk to the achievement of the Trust s strategic objectives being added to the Board Assurance Framework (BAF), and for the BAF to inform the divisional risk registers if necessary. Another key forum where information is shared between divisions and the Executive Directors is the regular monthly Executive Management Group, which is attended by Clinical Directors, General Managers, Divisional Lead Nurses and Executive Directors. It is used as an information-sharing and problem-solving forum, where good practice relating to management and mitigation of risks is also shared. All Band 7 or over staff within the Trust have recently received bespoke governance training, highlighting the importance of effective risk recognition, management, mitigation and reporting. This is a new development. The risk and control framework The Trust s Risk Management Strategy describes the organisation s values and strategic priorities against which key risks are identified and monitored. Key priorities for the management of those risks are defined, as well as performance measures against which the Trust will measure its success in the management of risk. The Trust s strategic aims define the vision of the Board of Directors of how the organisation s services should be delivered for those served by the Trust. They are the measure by which risk is assessed. The aims reflect the commitment made by the Trust to restore stakeholder confidence in quality, safety and governance following CQC and Monitor interventions, with the intention that the aims will also take the Trust beyond simply restoring confidence. The first step along this path was the removal of the Trust on 20 March 2013 from significant breach of its Terms of Authorisation. Page 2

125 The BAF sets out the key risks to the achievement of the Trust s strategic objectives and the mitigations against each risk. This provides a simple, comprehensive, but constantly evolving document, to inform discussions in regard to the management of strategic risk that could affect the delivery of strategic aims. Risk and safety priorities for the year were to strengthen and improve processes, systems and practices, and to better support staff to identify and effectively manage risk, in order to improve the safety of Trust services. To enable the Trust to measure how successfully it is managing risk, a number of risk indicators were developed. A risk register is updated monthly as a live document to ensure it reflects up to date risks and mitigations. Operational risks are escalated through divisional performance and risk meetings on a monthly basis as described above, and appropriate actions are discussed and agreed to reduce or manage operational risks. The BAF is reviewed by the Board on a quarterly basis, and the Quality and Performance Committee seeks assurance of the effectiveness of controls in place to manage the strategic risks via the relevant executive risk owner. In addition, annual internal audits are used to evaluate the successful day-to-day management of risk by the Trust. During the year the Board of Directors held a session specifically aimed at defining the organisation s risk appetite. During the year the Trust has undergone two external assessments against Monitor s Quality Governance Framework (QGF), and also conducted a number of its own assessments as part of the Integrated Governance Action Plan which was instigated as a result of the first external review in early Thorough review against each of the questions within the QGF has taken place, mapped to each of the four areas of strategy, capabilities and culture, structures and processes and measurement. On a scale where 20 represents the worst possible performance and zero the best possible performance, the Trust s score moved from 16 at the first assessment at the beginning of 2012/13, to 3.5 in February 2013, reflecting the enormous organisational focus on improving quality governance. Quality, safety and performance are discussed at the Performance and Risk Executive meetings on a monthly basis, in order for divisional leadership to be held to account for quality governance, and in turn the Executive Directors are held to account through the Quality and Performance Committee, where detailed information is presented, as well as through the Trust Board meetings. The Non-Executive Directors are held to account for their role of scrutinising performance by the Council of Governors, both informally through attendance at the public Trust Board meetings and on an on-going basis, and formally at the quarterly council meetings. Quality of performance information is a major focus for the organisation, and an internal audit report, referenced under the Review of Effectiveness section at the end of this statement confirmed that there was work needed to ensure data quality. This remains a key Trust priority. Assurance relating to compliance with CQC registration requirements is provided via the Trust s InCA (Integrated Compliance Assessment) tool which is used to assess compliance against CQC Essential Standards across all the Trust s services. This tool has been developed and implemented this year and has increased the awareness of performance in Page 3

126 relation to CQC Standards, allowing early identification of issues and therefore early implementation of mitigating actions. Periodic internal reviews of services are conducted, having been commissioned by the Board, as well as a planned series of Non-Executive Director visits to facilities as part of ensuring the quality of services. Specifically, risks to data security are managed via the normal governance structure and reporting process. The Information Governance Steering Group is responsible for overseeing Information Governance within the organisation and is chaired by the Director of Service Improvement. During the year information governance has also been reviewed as part of the process of preparation for the information governance toolkit submission. The organisation s major risks, as identified within the Board Assurance Framework reported to the Board of Directors as at the end of quarter 4, are detailed below: Risk Management/Mitigation Outcomes Patient safety could be compromised as a result of us being unable to meet the demand for Trust services. Clinical risk assessment of all referrals and ongoing risk assessments of waiting lists in place. Negotiations with commissioners regarding future service funding and commissioning of Trust services underway. Understood, clinically safe waiting times agreed with commissioners. Demonstration of Trust consistently achieving waiting time standards. Patient safety could be compromised as a result of us being unable to safely staff our wards. Operational staffing meetings in place across all inpatient sites to any immediate risks. Dedicated project in place to deliver safe staffing levels across the organisation. Clinically agreed establishment levels across all inpatient units. Demonstration of the consistent operation of our wards at establishment levels. Page 4

127 Risk Management/Mitigation Outcomes Failure in operational delivery as a result of the transition to the new service structures and associated redesign work. Trust re-organisation is subject to a dedicated project with associated support and governance. Comprehensive staff engagement process in place to support redesign and implementation of new service model. Implementation of new service model. On-going monitoring of patient safety incidents or other reports to ensure safe delivery of services. Inability to meet our financial commitments as a result of under delivery of the cost improvement programme and changing commissioning landscape. Establishment of CIP task and finish group to ensure development and delivery of costimprovement initiatives. Establishment of risk reserves within Trust financial plan. Robust approach of Trust to the negotiation of contracts with commissioners for FY14. Quality Impact Assessment on change programmes Delivery of CIP as planned. Delivery of planned financial risk rating. In terms of the integration of equality impact assessments into core Trust business, a revised policy for the Production and Management of Policies and Procedural documents was approved this year, specifically requiring those developing policies to have regard to the impact of their policy and therefore the operation of the organisation on equality. This takes the form of a statement within each policy relating to whether or not an equality assessment has taken place, and if it has been judged that one is not necessary, the reasoning for this. This will cascade through the development and revision of all policies, underlining the Trust s commitment to equality. The Quality and Performance Committee is the forum for the approval of policies within the organisation. All Incident reporting is openly encouraged throughout the Trust. This year a Serious Incident (SI) Group has been established, chaired by the Director of Nursing to review all Page 5

128 incidents, and to ensure learning is shared throughout the organisation. This information is triangulated with complaints and other patient experience information at a specific performance Triangulation Meeting, and at the Quality and Performance Committee, in order that themes can be identified across the Trust. The Board receives a monthly report on Serious Incidents. Following the improvement to our governance and reporting processes we have recently identified a number of underreported SIs that should have been reported as SIs but were only reported as incidents. We have immediately corrected this reporting, informed relevant parties and corrected this practice. To prevent this happening in the future, we have started a risk based review of our whole reporting and escalation processes in relation to the reporting, management and learning from incidents which will complete in the next couple of months. This process and its results will involve our Commissioners and Regulators fully. This year the Trust introduced an innovative patient safety initiative called Stop the Line, which, driven by pro-active executive-led communication, encourages staff at all levels to call a halt to any proceeding that is giving them cause for concern from a safety or quality perspective. From the most junior to the most senior members of staff, stopping the line is widely recognised throughout the Trust as a legitimate, non-confrontational way to halt proceedings and re-evaluate the situation before agreeing action to proceed. A process is in place, with rapid escalation of issues to divisional leadership and the Executive Directors, with an executive response promised within 24 hours. An addition has been made to the incident reporting form so the Trust is able to track such incidents in a coherent manner. This process highlights to staff the willingness of the Board to support any employee who raises concerns in good faith. Public stakeholders are involved in the management of risks that impact upon them, via elected representatives on the Council of Governors who hold the Board, and in particular the Non-Executive Directors to account for the identification and management of risks. Governors attend the public Board of Directors meetings, reflecting the Trust s commitment to default to openness as a matter of course. The newly-established Patient Ambassadors have enhanced the involvement of public and patients stakeholders enormously, highlighting issues within the Trust s facilities and assisting with the mitigation and resolution of issues identified, including risks. The Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission. 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 Pension 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. Page 6

129 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 UKCIP 2009 weather projects, to ensure that this organisation s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Review of economy, efficiency and effectiveness of the use of resources. The key process that has been applied to ensure that resources are used economically, efficiently and effectively involves a hierarchy of scrutiny of the use of resources throughout the Trust. The Audit and Assurance Committee has responsibility for ensuring that an effective system of integrated governance, risk management and internal control is in place to support the achievement of CPFT s strategic objectives. The Committee receives and considers reports from both Internal and External Auditors, and approves the Annual Report and Accounts for submission to the Board of Directors. The Committee exercises non-executive scrutiny over the Executive Directors for the efficient use of public funds. The Audit and Assurance Committee carries out a self assessment of its performance in line with the HFMA NHS Audit Committee handbook and made some small changes to its terms of reference to reflect best practice. Our Internal Auditors present a proposed schedule of audits to the Committee, which is then agreed, executed and reported upon. Via the Committee, the Executive Directors are held to account for any actions arising as a result of audit findings. The Audit and Assurance Committee reports to the Board of Directors and the Board seeks assurance from the Committee that it is satisfied that the Trust is using resources in an efficient and effective manner. This year in particular, the Trust has received an independent review of financial governance from an external provider, as part of the assessment process leading to deescalation from significant breach of its Terms of Authorisation. The outcome of this assessment was that there were sound financial governance processes in place, with one example being a new authorisation process for the approval of the use of temporary staffing at department level. Each division is held to account by the Board for the use of its resources via a Divisional Accountability and Governance Agreement (DAGA), which outlines specific levels of efficiency and effectiveness that divisions must attain in order to retain their authorisation. Annual Quality Report The Directors are required under the Health Act 2009 and the National Health Service (Quality Account) 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 2012/13. The Trust Board continuously strives for robust assurance over the quality of our clinical services in regard to the standards and performance targets. These include: national Page 7

130 standards (CQC essential standards of quality and safety, NHSLA standards, national service standards), targets set by the NHS Outcomes Framework, local commissioning targets such as CQUIN and contractual quality targets, local targets agreed by the Trust Board, Trust policy standards and quality priorities. The Trust has taken steps to assure the Board that the Quality Accounts presents a balanced view of quality and that there are appropriate controls in place to ensure the accuracy of data that it contains. Our quality assurance framework is outlined below. The Quality and Performance Committee has over arching responsibility for quality in the Trust. It is chaired by a Non-Executive Director and meets monthly. The Committee is supported by five executive groups. These are the Management Executive Group, Performance and Risk Executive, Finance and Infrastructure Executive, Clinical Executive and the Workforce Executive. The Management Executive Group, which is chaired by the Chief Executive, has a management role over the other four executive groups. The Quality and Performance Committee, together with the executive groups, set the strategic direction of the Trust on behalf of the Trust Board in matters relating to quality and performance. The Director of Nursing, together with the Medical Director, have the Executive Lead for clinical quality, governance and safety, and they report into the Quality and Performance Committee and the Trust Board monthly. Our divisional leadership structure consists of a Clinical Director, General Manager and Nurse Lead who are responsible for quality and safety of our services at service level. We have a quality dashboard which is mapped against the CQC Essential Standards of Quality and Safety, and includes national, contractual and local quality and performance indicators. During the year, this was translated into divisional dashboards so that each clinical team has its own set of measures and performance indicators that informs decision making and service developments. Quality and performance data is collected, triangulated and reported monthly to provide the Trust Board with timely information on how well the Trust is meeting its objectives, priorities and targets. Each clinical team has a risk register that feeds into the Trust s Risk Register and Board Assurance Framework. This enables the Trust to manage risks effectively and act on gaps in compliance in a timely manner. The Trust has a programme of clinical and non-clinical audit, both internal and external, to examine our compliance with standards of practice and service delivery, and identify areas for improvement. A summary of the Trust s participation in national and local clinical audit is outlined in Part 2 of the Quality Report. During the year, we developed Integrated Compliance Assessment (InCA) tool to enable us to monitor and report on our compliance with the CQC essential standards. We take part in national accreditation schemes to provide us with assurance that out services meet the highest standards set by professional bodies and enable us to benchmark our services and practice with other Trusts across the country. We also commission specific reviews of our services from external providers, such as the review of our quality and governance arrangements and the review of our selected Serious Incidents by Professor Appleby of Manchester University. During the year, the CQC visited our premises on two occasions to review our compliance with the essential standards of quality and safety. Our current status is Registered Without Page 8

131 Conditions. We also had eight visits to review our compliance with the Mental Health Act, and received positive feedback. We currently have level 2 accreditation with the NHSLA. These provide the Board with additional external assurance about the quality of our services. Our practice is governed by a range of policies, protocols, guidelines and procedures that provide our staff with appropriate standards that meet national and professional requirements. There are mechanisms in place to monitor compliance with these policies and other procedural documents that guide practice. The Trust has systems and processes in place for the recording, collection, analysis and reporting of data which ensures that data is accurate, reliable, timely and complete. These are integrated into the management processes of the Trust and support day-to-day operations. Our information systems have built-in controls that are regularly reviewed to minimise the scope of human error or manipulation and reduce the incidence of erroneous data entry, missing data or unauthorised data changes. Roles and responsibilities in relation to data quality are clearly defined and where appropriate, incorporated into job descriptions. Staff receive training to support them in implementing the appropriate policies and procedures relating to data collection and recording. We are currently in the process of introducing electronic patient records system (RiO and Systm1) across the Trust to help us ensure that data is recorded, shared, utilised and reported on to help us provide safe and effective services. The Auditors review of the quality report has identified a small number of instances where the underlying data did not support the reported performance. The auditors were unable to conclude whether these were isolated incidents. To address these areas the Trust plans to implement the recently developed Data Quality Improvement Project to improve on aspects of data quality. We also employ a range of measures to ensure open and effective communication with our staff and promote engagement and ownership of matters that are important to the Trust. This has informed the development of our Quality Diamond Strategy that underpins our targets, objectives and quality priorities. We have discussed and consulted with our key stakeholders in the development of our Quality Report, which includes our staff, governors, commissioners and relevant local health bodies such as the local Healthwatch and the Overview and Scrutiny Committees. The Quality Report has been subjected to a limited assurance review under external scrutiny, conducted in accordance with the 2012/13 Detailed Guidance for External Assurance on Quality Reports performed by our external auditors.. 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 Page 9

132 Report attached to this Annual Report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit and Assurance Committee and the Quality and Performance Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. The board of directors role is to determine the overall strategic direction and to provide active leadership of the Trust within a framework of prudent, effective controls which enables risk to be assessed and managed. During the course of the year there has been a considerable review of the Trust s Quality Governance processes. These reviews and the changes that followed the reviews have been independently assessed by an external provider and Monitor and were a key factor in the regulators decision to remove the Trust from its position of significant breach of the terms of its authorisation. The Board has proactively sought to implement the recommendations made in the May 2012 Quality Governance Review and to significantly improve quality of care at the Trust. There has been significant investment of both time and resources, including the development of the Quality Diamond, the reorganisation of the divisional structures and management, and the establishment of a PMO to oversee the process and to hold staff and management to account. There has been significant involvement from Board members in a number of these projects; for example, many of the Executive and Non-Executive Directors are involved in the Task and Finish Groups, which have been set up by the Trust to progress projects such as the workforce redesign and cost improvement programmes. The Trust has made a number of adjustments to its organisational structure, including a reduction in the number of divisions from five to three, and changes to the management structure at a divisional level. These changes are relatively new, and it will take time to embed these fully. The operation of the Trust s Committee for quality, the Quality and Performance Committee, has been reviewed and changes made to the agenda, membership and the way by which the Committee reports to the Board. The Committee now has three Non- Executive members, which has enhanced the level of challenge and scrutiny that information receives before it reaches the Board. The Trust has a programme of both internal and clinical audit, which includes audits relevant to quality, including data quality behind performance measures, care planning, incident reporting and medicines management. These audit functions report to the Board sub-committees by exception, and the sub-committees also review progress against plan. The divisional management teams are developing processes to ensure that whilst risks can be escalated to the Board through the division, services are supported to manage their own risks where appropriate. To improve this process, the Executive Team has developed governance training. This training has been provided to the Board, divisional management, and to service level management. Page 10

133 The Trust has implemented a number of actions to improve financial controls within the Trust, in particular over authorisation of capital works, monitoring of performance against CQUIN targets, authorisation of temporary staffing expenditure, cash flow forecasting and reporting and reporting of financial performance at service, divisional and Board level. The changes made by the Trust have enhanced these controls, and will provide the Board with greater assurance over the levels of revenue and expenditure at the Trust. Many of these revised controls have been in place for only a short period of time, and will therefore require further embedding. The Trust has ensured that the key changes are all covered in the FY14 internal audit plan, to assess the operation of these revised controls. The Trust received Internal Audit Services from Parkhill from April to December 2012 and from RSM Tenon from January to March The Interim Head of Internal Audit Opinion (HoIAO) on the effectiveness of the system of internal control for the period 1 April to 31 December 2012 stated that: Limited assurance can be given as there are weaknesses in the design and/or inconsistent application of controls which could put the achievement of the organisation s objectives at risk. This opinion related to reviews of quality and productivity performance management, a capital project, Human Resources and e-rostering. A review of Quality and Productivity performance management examined ten performance indicators; three of which were the mandatory quality performance indicators (as prescribed by Monitor in the 2012/13 Compliance Framework) In relation to the Monitor performance indicator for seven day follow ups the review was unable to validate a number of records back to source documentation.. Actions taken as a result of this include a standard operating procedure for RiO (The Trust s new Electronic Patient Record) which will support the routine capture of seven-day follow-up data, periodic verification checks as part of the Mental Health Act (MHA) monitoring programme, in relation to reading of rights, a new protocol for the extracting and monitoring of mandatory training data, and a data cleansing exercise for the Electronic Staff Record (ESR). The opinion regarding a capital project related to the Trust s anti-ligature works as part of the Environment and IT Turnaround Project. The independent review identified a lack of compliance with the Trust s established systems and processes. Actions taken as a result of this finding are the approval of new policies and procedures which cover Capital and Revenue Business Case approval, which consists of a four stage approvals process including; Project initiation, to ensure that the Finance Director approves progress to the next stage; Strategic Outline Case, to clearly articulate the reason for change and to ensure that any proposed investment is both consistent with the Trust s strategic direction and affordable to the Trust and Commissioners; Outline Business Case, to identify the preferred option for the project through an objective investment appraisal process; and Page 11

134 Full Business Case, to ensure that schemes will only be progressed when capital/revenue funds have been identified and commissioner support obtained, that a preferred option is re-appraisal with detailed cost information and plans for managing the project and its implementation. A review of the Trusts performance against its disciplinary process identified a number of cases where the Trust had exceeded the timeline for completing the process as set out in the Trust s disciplinary policy. Actions taken as a result of this finding included revisions to the appropriate policy and procedure and tightening of the performance management reporting in this area.. A review of the Trusts new e-rostering system identified weakness s regarding the timely approval of rosters, which had resulted in a number of rosters being approved after their commencement, and it was also noted that the Key Performance Indicator relating to the percentage of staff taking leave in any one week was regularly not being met. Actions taken as a result of this finding are specific training for all ward managers, increased involvement of Modern Matrons in the monitoring of finalised rosters and routine monitoring by the Operations Centre Manager to improve the timeliness of completed rotas. The Head of Internal Audit Opinion (HoIAO) on the effectiveness of the system of internal control for the period 1 January to 31 March 2013 stated Conclusion Based on the work undertaken in 2012/13 from the 1st January 2013 to date, significant assurance can be given that there is a sound system of internal control which is designed to meet the organisation s objectives, and that controls are being consistently applied in all the areas reviewed. As Accounting Officer and based on the review process outlined above, I conclude that the Trust has identified and has taken the necessary action on the control issues during the year which have been identified in detail in the body of the Annual Governance Statement (AGS) above. The external reviews of Quality and Corporate Governance undertaken provide further assurance to this effect, as does the actions of the regulator in removing the Trust from breach of the terms of its authorisation in March Signed Chief Executive Date: 24 May 2013 Page 12

135 Agenda Item: 9 Trust Board REPORT Subject: Quality Account 2013 Date: 24 th May 2013 Author: Director of Nursing Lead Director: Chief Executive Executive Summary: This paper presents a summary of the Quality Report Our overall aim for this report is one of openness, transparency and accountability while at the same time presenting a strong message of our commitment to quality throughout the report. The key exceptions in the report are outlined below. Highlight 1: Our performance against targets in 2012/13 We have met four out of our nine quality priorities for 2012/13, one partially met and four not met. A review of our quality priorities set in previous years show that we have met three out of six priorities and partially met three from 2010/11; and met five out of six quality priorities and partially met one from 2011/12. We have met six out of our eight CQUIN goals for 2012/13. Highlight 2: Our quality priorities for 2013/14 We have identified nine quality priorities for 2013/14 which we believe will make a real impact on improving the care and outcomes for our patients. Highlight 3: Our performance in patient safety incidents Our rate of patient safety incidents and those that result in severe harm or death are around twice the national average. Highlight 4: Our performance in staff and patient surveys The results of our patient surveys (both national and internal) show positive improvements overall, particularly around patient satisfaction on the quality of their relationship with our staff. On the other hand, our scores for the Friends and Family test (NPS) are reflected in the bottom 5 scores for both Meridian inpatient and community patient surveys. The results of our national Staff Survey show us to be in the lowest quartile, with our score on the Friends and Family test being the lowest in the country. Highlight 5: Our performance in other quality performance indicators We have done well on the other quality performance indicators, including the Monitor requirements (key national priorities) and locally agreed quality indicators, although there remain areas for further improvement, notably our reading of Rights and Breastfeeding targets. Conversely, we have done very well on MRSA screening, care planning and participation in national accreditation schemes. Page 1 of 7

136 Recommendations: Board is asked to Sign off Quality Account Relevant Strategic Priorities (please mark in bold) Our services will be recognised as world class We will develop service plans that achieve financial stability We will develop our built environment and technology infrastructure to deliver our vision Links to BAF/Corporate Risk Register We will deliver care through engaged and empowered people We will develop strong relationships based on trust and mutual respect with key stakeholders Details of additional risks associated with this paper (may include CQC Essential standards, NHSLA, NHS Constitution) Financial implications/impact Legal implications/impact Partnership working and public engagement implications/impact Committees/groups where this item has been presented before Has a QIA been completed? If yes provide brief details Non-achievement of our quality priorities and quality dashboard will risk non compliance with the CQC and NHSLA standards. Non compliance with the CQC and NHSLA standards impact on our Monitor ratings and contractual requirements with our commissioners. Compliance with the CQC standards is a statutory requirement. Our quality priorities are agreed in discussion and collaboration with our partner agencies. Audit % Assurance Committee, Executive Management Group and the Trust Board Page 2 of 7

137 QUALITY REPORT INTRODUCTION This paper presents a summary of the Quality Report Our overall aim for this report is one of openness, transparency and accountability while at the same time presenting a strong message of our commitment to quality throughout the report. There are key areas where we have under performed and we will focus our efforts and resources on these in 2013/14. Moving forward, we will strengthen our approach towards monitoring our performance on the mandated requirements of the Quality Accounts in order to put us in a stronger position for our Quality Report KEY EXCEPTIONS Details are available in the full report. Highlight 1: Our performance against targets in 2012/13 a. Quality Priorities 2012/13 We have met four out of our nine quality priorities for 2012/13, one partially met and four not met. The quality priorities that we have met in 2012/13 are listed below: o Full compliance with CQC standards o 95% of care plans will sustainable achieve 7Cs standards o 30% patients will recommend CPFT to family and friends o All premises will achieve at least 4 stars against our environmental standards We were just under the target of having 95% of our staff will have completed their mandatory training. We have not met the following quality priorities in 2012/13 and actions are underway to achieve full compliance with these priorities in 2013/14.: o 85% of our people will describe IT response times as good or very good o 85% of our people will state that they are able to make changes necessary for excellent patient care o We will achieve national upper 20% in the number of our people who state that they will recommend CPFT to their family and friends as a place to work o No more than 5% of bank and agency shifts will be used as a proportion of total shifts used on the ward Part of the reason for this may be that the targets we set ourselves in the beginning of last year were too high and unrealistic. For 2013/14, we will aim to have stretching but achievable targets. b. Pervious Year s Quality Priorities It is important to review performance against our quality priorities set in 2010/11 and 2011/12 as of March 2013 to show continuity between our accounts as time progresses. The DH guidance states that organisations need to assure readers that the quality achieved in the previous year for a given area will not reduce if it is no longer a priority for the coming year. An explanation of how the quality will continue to be measured, maintained and developed should be included when retiring priorities from future Quality Accounts. This is what we have done in this year s Quality Report Page 3 of 7

138 A review of our performance on previous year s quality priorities shows that we have met three out of six priorities and partially met three from 2010/11; and met five out of six quality priorities and partially met one from 2011/12. The priorities that we have met as of 2012/13 are listed below 2010/11 Improvement in annual patient survey responses for overall satisfaction rating Ensure 95% of patients have a care plan Compliance with 18 week referral to treatment waiting time targets 2011/12 To develop routine patient feedback mechanisms across all care pathways To develop and implement a Carer Strategy Reduce the risk of absconsions Significantly strengthening patient safety training in adult safeguarding, clinical risk assessment and physical observations To develop and implement a consistent measure which involves service users directly in planning their care The priorities that we have not met as of 2012/13 are listed below 2010/11 Reduce all suicides by patients in contact with secondary mental health services by 20% by 2013 Reduce the number of physical assaults within Trust services by 20% by 2013 Ensure that 95% of CPA patients have a HoNOS assessment in a 12 month period 2011/12 To establish with primary care a Suicide Prevention Strategy Performance The number of suicide and probable suicides reduced by 11% between 2010/11 and 2012/13 The number of physical assaults reduced by 11% between 2010/11 and 2012/13 As of March 2013, only 85% of our CPA patients have a HoNOS assessment We have developed a Suicide Prevention Strategy which is being presented to this committee for approval this month CQUIN Goals We have met six out of our eight CQUIN goals for 2012/13. The two goals we have not met during the year are: Goal 4: Clinical staff working in the agreed areas have appropriate knowledge and skills to make a brief advice intervention for alcohol/smoking or both and to signpost or refer as appropriate in line with the.making every contact count initiative Goal 5: Routine reporting of outcome measures for each of CAMH (IAPT), Adult (Recovery star) and OPMG CORE 10 and QALY AD We provided an e-learning package but we did not meet the target as of March We will continue to roll out the e-learning package for the remainder of 2013/14 Performance against the targets in the three areas identified were variable as of March Please refer to the full report for details. Page 4 of 7

139 Highlight 2: Our quality priorities for 2013/14 We have identified nine quality priorities for 2013/14 which we believe will make a real impact on improving the care and outcomes for our patients. These are: Patient Experience o 65% of our patients will be happy to recommend our services to their family and friends o 60%of our staff will recommend CPFT to care for their family and friends o 60% of our staff will recommend CPFT to family and friends as a good place to work Patient Safety o Our teams will achieve a Trust wide average InCA score of 95% by Qtr 4 of 2013/14 o 95% of our people will complete safeguarding adults and safeguarding children training o 65% of our people will describe IT response times as good or very good Clinical Effectiveness o 98% of relevant admissions to our acute wards will be gatekept by CRHTT o Achieve 60% national target in the proportion of people referred for psychological therapy who receive psychological therapy o Improve physical health monitoring and outcomes for our patients The rationale, measurement and monitoring arrangements for these quality priorities are set out in the full report. Highlight 3: Our performance in patient safety incidents For 2012/13, one of the mandatory core quality indicators is around the number and rate of patient safety incidents and the proportion of patient safety incidents that result in severe harm or death. The data are derived from the last two periods reported in the Health & Social Care Information Centre (HSCIC) indicator portal, benchmarked against data from all health and social care providers in England. Note: The data available from HSCIC is only the period up to March 2012 hence we have provided data available from our Datix system to present data for 2012/13 Performance: o Our rate of patient safety incidents are twice the national average and a third of the highest reported data. We are in the highest quartile of 57 reporting mental health Trusts in England and a higher proportion of our incidents result in no harm compared to other mental health Trusts which is indicative of a good culture of reporting in the Trust. Note: The NRLS (National Reporting & Learning System) removes incidents reported that they do not consider to be patient safety related. o A slightly higher proportion of our reported incidents result in moderate harm and death. We also report higher rates of self harming behaviour, and significantly less incidents around medication and patient accidents. On the other hand, the proportion of our patient safety incidents that resulted in severe harm or death was only around only 2% in 2011/12. o The number of incidents resulting in severe harm or death is showing a 14% reduction in 2012/13, which comprise 1.4% of our total patient safety incidents for the year. This reflects positively on the huge amount of work we have undertaken in the past year on improving the safety of our environment (e.g., removal of ligature points and risks for absconsions). Page 5 of 7

140 Highlight 4: Our performance in patient surveys Patient surveys o The results of our patient surveys (both national and internal) show improvements overall, particularly around patient satisfaction on the quality of their relationship with our staff. o Data available from our national community patient surveys over the years show a steadily increasing trend for quality of care overall o On the other hand, our scores for the Friends and Family test (NPS) are reflected in the bottom 5 scores for both Meridian inpatient and community patient surveys. The average sore for the year from inpatient units is 20%, and 61% for community patients. o Key areas requiring improvements are around the quality of food and recoverybased services Developmental work is required to improve the level of patient satisfaction particularly in our inpatient wards. Staff survey The results of our national Staff Survey show us to be in the lowest quartile, with our score on the Friends and Family test being the lowest in the country at 33%, while our Pulse Survey scores for the same item show a much higher rate of 48%. We are in the lowest 20% for overall patient satisfaction rates, and have the lowest score overall in the Family and Friends test. Key actions are: A range of actions have been developed to ensure improvements in our staff survey scores for 2013/14. Highlight 5: Our performance in other quality performance indicators We have done well on the other national and locally agreed quality performance indicators, as follows: o We have performed well in other mandated requirements (pg 20 - eg, clinical audit, R&D, CQC registration, MHA inspections) o We have met all of the Monitor (key national priorities) for the year (pg 40) o We have performed very well on the quality of our care plans, which is supported by the results of the national community patient survey 2012; MRSA screening targets, and participation in national accreditation schemes (pg 46) o We achieved Green rating from our Information Governance toolkit (pg 21) However, there remain areas for further improvement, notably our reading of Rights and Breastfeeding targets. b. PLAN FOR 2013/14 The Quality Accounts was developed as a framework with which to focus the resources of NHS Trusts and ensure a continuing process of quality improvement. We need to make better use of this framework to ensure that we achieve our targets and quality improvement priorities for 2013/14. For 2013/14 it is proposed that: we review and streamline the quality dashboard to focus our efforts and resources on those key quality areas and core quality performance indicators that directly impact on the quality and outcomes of patient care. the Quality & Safety report is based on the Quality Accounts reporting framework Page 6 of 7

141 regular progress reports on our performance against the Quality Accounts is put in place, with an interim report presented to the Trust Board at the end of Qtr 2, Qtr 3 and end of year reporting period. This will enable the organisation to identify the risk of non-achievement of the priorities and targets so that mitigating factors and corrective actions are taken in a timely manner. c. RECOMMENDATIONS Board is requested to sign off the Quality Account Page 7 of 7

142 QUALITY REPORT 2012/13 DRAFT 3

143 CONTENTS INTRODUCTION TO THE QUALITY ACCOUNT All NHS Trusts are required to produce an annual Quality Report. The purpose of this report is to show how well we have performed in the past year and the areas where we feel we could make further improvements. We aim for transparency and openness to provide you with accurate, appropriate and sufficient information with which to assess our performance and the priorities we have set for the future. The key requirements of the Quality Report are set out in three sections below. PART 1: STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE This is a statement from our Chief Executive, Dr. Attila Vegh, on behalf of the Board of Directors setting out what quality means to us, what improvements we have made in the past year and where we need to make further improvements, and our vision for the future. Chief Executive s Statement 3 PART 2: PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF ASSURANCE We present our strategic objectives that we believe will help us achieve our goal of becoming a top 5 mental and community healthcare provider. We also review our progress on quality priorities in 2012/13 identified in our 2011/12 Quality Report and in previous years, and outline our quality improvement priorities for 2013/14. The Statement of Assurance is a mandatory requirement and we confirm that the Trust is able to meet all of the mandated requirements for the Trust. Priorities for Improvement 6 Statements of Assurance Mandatory Core Set of Quality Indicators PART 3: OTHER INFORMATION We report on performance against key national priorities and local quality performance indicators. Review of Performance Against Other CPFT Quality Indicators and Key National Priorities 40 ANNEX ANNEX 1 Our Quality Diamond Strategy ANNEX 2 Definitions of Key National Quality Indicators ANNEX 3 Statements from the Clinical Commissioning Board, the Local Healthwatch and Overview and Scrutiny Committee ANNEX 4 Statement of Directors' Responsibilities in Respect of the Quality Report ANNEX 5 External Audit Report Page 2 of 66 Draft May2013/WLlaneza

144 PART ONE: A STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE Introduction I am delighted to present our fourth Quality Report, and my second as Chief Executive of Cambridgeshire and Peterborough NHS Foundation Trust (CPFT). Over the past year, we have achieved many great things which I am very proud to present to you in this report. What do we mean by quality? Quality is at the core of everything we do, it is inherent within our values, our mission and our vision. We view quality from the perspective of the people who experience it - our patients, their families and carers, visitors to our premises and our staff and this underpins our priorities for quality which are outlined below. Back in 2011 we developed a Quality Dashboard, mapped against the Care Quality Commission s Essential Standards of Quality and Safety, which sets out the key areas that we felt we could reliably measure and that would tell us whether or not we are providing a good service. During the year, this was translated into Divisional quality dashboards and embedded into our reporting and governance framework. For 2013/14, we will focus on our vision to become a top 5 mental and community healthcare provider. To help us achieve this goal, we have developed four strategic objectives which are outlined in our Quality Diamond Strategy. They cover the areas of patient safety, patient experience, staff engagement and value for money. We have also reviewed our progress on quality priorities identified in previous years which were set around the three domains of quality patient experience, patient safety and clinical effectiveness. We believe these quality objectives and priorities will further improve the care and outcomes for the people who use our services, and also the experience and well being of our staff. Our staff have helped us to identify these priorities through a series of Town Hall events organised across the organisation to find out what their views were and what they thought was important. We have also worked with our commissioners, governors and other key partners; and also reviewed the range of data and other information that was available to us, including information from audits, incidents, comments and complaints about our services, and the results of service reviews to help us identify the areas that we need to focus on for improvement in 2013/14. What have we done well this year? Two years ago, CPFT was judged non-compliant in seven of the CQC standards of care and was considered one of the worst performing Trusts in the East of England. I took up my post as Chief Executive of the Trust in October 2011 and we began the difficult and challenging work of turning the Trust around. Coming into 2012/13, we were faced with many difficult challenges. We were still non-compliant in two of the CQC standards and had improvement actions required in two more. Following an inspection in June 2012, we were found to be non-compliant in one other standard around the management of medicines. As we approached the end of 2012/13, we were declared fully compliant across the organisation. This is a massive achievement and I believe the most important for CPFT to date and this is all down to the phenomenal hard work and dedication shown by our staff. Without them, this wouldn t have been possible. We also reviewed our governance and operational structures to further strengthen our systems and processes and help us deliver on our objectives and priorities. In January 2013, we implemented our new governance framework. Our Clinical Divisions were reduced from five to three, and developed around diagnosis and needs as opposed to age groups. We believe that this will enable us to deliver better care and outcomes for the people who use our services. In terms of our Quality Accounts, we have met four out of nine quality priorities for 2012/13 and partially met one, and six out of eight CQUIN goals for the year. Page 3 of 66 Draft May2013/WLlaneza

145 But that is not all. Despite the areas of concern highlighted by the CQC, we have continued to excel in our practice and service delivery. Some of the many achievements CPFT have made over the past year are outlined below. In June 2012 the Cambridgeshire Child and Adolescent Substance Use Service (CASUS) won the Virgin Business Media and Guardian s innovation nation award for collaboration. CASUS is part of the AMBIT collaboration - a group of teams who are all working with extremely vulnerable and high-risk youth who have multiple and complex problems. CPFT s Youth Offending Service was rated in the top 5 in the UK CPFT s Dementia Carers Support Service won a Cambridge News Community Award. The opening a new dementia research facility at the refurbished Windsor House in Fulbourn. The facility is the new home of the Dementia and Neurodegenerative Diseases Research Network East Anglia. The opening of Recovery College East, the first of its kind in the East of England. Courses will be held at venues throughout Cambridgeshire and Peterborough, and will include subjects such as helping people return to employment, staying well at work, getting the best from mental health services and physical health and recovery. CPFT was re-awarded the Ministry of Defence contract to provide local in-patient mental health care for serving military personnel in the eastern region at The Cavell Centre in Peterborough. What do we need to do better? We recognise that we have a lot do to rebuild staff morale in the coming year. Successfully implementing a major turnaround programme required a lot of hard work and changes to our ways of working and this has been reflected in our staff survey scores in 2012, both from the national survey and our internal Pulse Surveys. Our commitment to our staff is embedded in our Quality Diamond Strategy through the initiatives to become a top 5 community and mental health organisation for staff engagement. Over the coming months, we will introduce a range of initiatives to improve the experience of our staff. We also need to focus on the areas in our Quality Priorities where we have not met the targets set in 2011/12. This includes better compliance with our mandatory training programme and improving staff satisfaction with the response times to IT requests. We have developed a range of actions to help us do this, which is outlined in Part 2 of this report. In addition, we have identified other areas where we need to do better particularly around provision of psychological therapies and physical health monitoring and outcomes for our patients. These are included in our priorities for 2013/14. A huge thanks to our staff All of the achievements we have made in the past year would not have been possible without the hard work, dedication and commitment of our staff so I would like to take this opportunity to formally thank our staff for everything that they have done which has brought us to where we are today. I am very proud of every member of our staff and I know that together, we have the capability and energy to continue to achieve many more great things in the years to come. Some of the many initiatives we have started during the year to show our appreciation to our staff include giving out the Quality Heroes and the Quality Champion awards. We also celebrated our very first ever Staff Awards ceremony in February 2013, to recognise the achievements of individuals in categories of patient experience, patient safety, staff engagement, productivity, good governance and research innovation and education, among others. Over the coming months, we will continue to think of ways to thank our staff and recognise their achievements. What others think of us? We welcome opportunities for external bodies to review our services to see how well we are meeting the standards of quality and safety. During the year, the CQC assessed our services against these standards on two occasions and they have judged us fully compliant against the standards they examined. They also conducted specific visits to review our compliance with the Page 4 of 66 Draft May2013/WLlaneza

146 Mental Health Act. I am proud to say that the feedback we have received has been extremely positive. We took part in a number of accreditation schemes during the year. For example, The Croft Child and Family Centre was accredited by QNIC (Quality Network for Inpatient CAMHS) in October 2012, and our Adults and Learning Disability inpatient units are accredited under AIMS (Accreditation for Inpatient Mental Health Services). We also value the comments and learning that we get from PALS (Patient Advice and Liaison Service) and Complaints and also from the results of our internal patient and staff survey as these give us a very useful insight into the areas that we can and need to improve. Statement of accuracy I confirm that to the best of my knowledge the information in this document is accurate. DR ATILLA VEGH CHIEF EXECUTIVE 24 MAY 2013 Page 5 of 66 Draft May2013/WLlaneza

147 PART TWO: PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF ASSURANCE FROM THE BOARD 1.0 PRIORITIES FOR IMPROVEMENT In this section we introduce our overarching strategy for quality which is embedded in our Quality Diamond Strategy below. We also report on our performance in 2012/13 against the quality priorities set in 2011/12. It is important to show continuity when reviewing quality priorities between accounts especially where priorities have changed over time. We therefore look back at our priorities from previous years and provide an update on progress we have made during 2012/13 and state how we will continue to measure, maintain and develop these priority areas. Finally, we present our quality priorities for 2013/ QUALITY DIAMOND STRATEGY 2011/12 was a difficult and challenging year for the Trust due to the demands placed on the organisation to consistently achieve all of the CQC essential standards of quality and safety. During 2012/13 we also developed our ambition to become a top 5 mental and community healthcare provider which we have outlined over the following pages. At the beginning of 2012/13, we started work to build on our successes and look forward to 2013/14. The second phase of the staff Town Hall events was held in June 2012 to identify the key areas that everyone within the organisation wanted to prioritise in order to improve the quality and experience of our services. Over 2,000 of our staff attended the events and their ideas have helped us to formulate our strategic objectives for 2013/14. These strategic objectives are outlined within the Quality Diamond which we published in December 2012, and are shown in the diagram on this page. The four strategic objectives are: To become top 5 nationally for patient safety To become top 5 nationally for patient experience To become top 5 nationally for engaged staff To become top 5 nationally for value for money We have set out further details in Annex 1. Our Quality Diamond Strategy underlines our quality priorities and quality dashboard for 2013/14. We have already started implementing a number of these initiatives, and over the coming months we will continue to roll out a series of actions and initiatives to support the achievement of these objectives. We will publish regular reports on our progress against the Quality Diamond priorities on our public website. Page 6 of 66 Draft May2013/WLlaneza

148 Clinical Effectiveness Patient Safety Patient Experience A Review of Our Quality Priorities for Improvement 2010/ / / /14 Priority 1 Improvement in annual Patient Survey responses for overall satisfaction rating Priority 2 Ensure 95% of patients have a care plan Priority 1 To develop routine patient feedback mechanisms across all care pathways Priority 2 To develop and implement a Carer Strategy Priority 1 To provide safe and effective care which provide excellent customer services 1. Full compliance with CQC standards 2. 95% of care plans across the Trust will sustainably achieve 7Cs standards 3. 80% inpatients and 74% community patients will recommend CPFT to family & friends Priority 1 To improve the experience of our patients and our staff 1. 65% of our patients will be happy to recommend our services to their family and friends % of our staff will recommend CPFT to care for their family and friends 3. 60% of our staff will recommend CPFT to family and friends as a good place to work Priority 3 Reduce all suicides by patients in contact with secondary mental health services by 20% by 2013 Priority 4 Reduce the number of physical assaults within Trust services by 20% by 2013 Priority 3 To establish with primary care a Suicide Prevention Strategy Priority 4 Reduce the risk of absconsion through a review of clinical risk assessment observations, access and therapeutic programmes Priority 5 Significantly strengthening patient safety training in adult safeguarding, clinical risk assessment and physical interventions Priority 2 To provide an estate and IT infrastructure that is safe, moderns and fit for purpose. 1. All premises will achieve at least 4 stars against our environmental standards 2. 85% of our people will describe IT response times as good or very good Priority 2 To strengthen the culture of safety in CPFT. 4. Our teams will achieve a Trust wide average InCA score of 95% by Qtr4 of 2013/ % of our people will complete safeguarding adults and safeguarding children training 6. 65% of our people will describe IT response times as good or very good Priority 5 Compliance with 18 week referral to treatment waiting time target Priority 6 Ensure that 95% of CPA patients have a HoNOS outcome assessment in a 12 month period Priority 6 To develop and implement a consistent recovery outcome measure which involves service users directly in planning their care Priority 3 To provide services through empowered staff with the right skills, attitudes and behaviour 1. 85% of our people will state they are able to make changes they feel necessary for excellent patient care 2. We will achieve national upper 20% in the number of our people who state that they will recommend CPFT to their family and friends as a place to work 3. 95% of our people will have completed all their mandatory training 4. No more than 5% of our inpatient shifts will have temporary staff greater than 20% of all staff at work Priority 3 To improve outcomes of care for our patients 1. 98% of relevant admissions to our acute wards gatekept by Crisis Resolution Home Treatment Team 2. Achieve the 60% national target in the proportion of people referred for psychological therapy who receive psychological therapy 3. Improve physical health outcomes for our patients Page 7 of 66 Draft May2013/WLlaneza

149 1.2 REVIEW OF QUALITY PRIORITIES 2012/13 We have reviewed our performance against the nine indicators within our quality priorities for 2012/13. We have fully met four indicators, partially met one and not met four. This is described below PRIORITY 1: PATIENT EXPERIENCE 2012/13 Priority To provide safe and effective care which provide excellent customer experience. Trust indicators 1. Full compliance with the Care Quality Commission (CQC) Essential Standards for Quality & Safety in any Trust registered location 2. 95% of care plans across the Trust will sustainably achieve the 7Cs standards % of inpatients and 74% of community service users will recommend CPFT to their family and friends Performance 1. Full compliance with the Care Quality Commission (CQC) Essential Standards for Quality & Safety in any Trust registered location As of March 2013, the current registration status of CPFT with the CQC is Registered Without Conditions. Please refer to section 2.6 for further details on our achievements in this area % of care plans across the Trust will sustainably achieve the 7Cs standards. The 7Cs standards were developed to help us drive up the quality of our assessments and care planning processes and documentation. The 7Cs assessment process was later incorporated into the InCA (Integrated Compliance Assessment) process. Thresholds were set on an incremental basis from 75% to 95%. The overall Trust average score for Quarter 4 is 93% across all participating teams. 7Cs scores are reported through our quality dashboards. It is worth noting that the results of our National Community Patient Survey 2012 show improvements in our scores overall, with the biggest improvements in the questions around care planning. Please refer to section for further details. Quality improvements Care Planning Guidelines booklet developed to support the 7Cs standards and to articulate the standards around involvement of patients and carers in the assessment & care planning process Care Planning Policy was reviewed and updated to clarify required standards of practice and incorporate the 7Cs standards. InCA was developed as an Excel-based tool and later converted into an ipad application in September This is used to assess and provide assurance of compliance with all 16 CQC Outcomes on a monthly basis and incorporates our 7Cs care planning and 5 star environmental standards. Teams undertake self assessments with quarterly peer reviews. Page 8 of 66 Draft May2013/WLlaneza

150 3. 80% of inpatients and 74% of community service users will recommend CPFT to their friends and family This target was originally set based on the results of the national patient surveys for both inpatients and community services. During 2012/13, however, CPFT along with many others in the East of England (EoE), decided, at the instigation of the EoE Strategic Health Authority, to change the way that this indicator was calculated to one based on the net promoter score (NPS) methodology. This resulted in the revisions to the targets that are set out below. The average score for the Trust and its constituent Divisions as at year end March 2013 are shown in Table 1 below. Table 1: Family & friends test Division Revised Target Performance as of 12/13 March 2013 Acute Care Service 30% 26% Community Service 30% 62% Specialist Service 30% 34% Total Trust average score March % Overall, the Trust has exceeded the targets for this indicator although recognising that patient experience is variable across our different Divisions. In 2013/14 we have agreed differential targets for patient experience to reflect the nature of the services we provide. This has been carried forward as our quality priority for 2013/14 with an ambition to see substantial improvements across all three Divisions. Page 9 of 66 Draft May2013/WLlaneza

151 1.2.2 PRIORITY 2: PATIENT SAFETY 2012/13 Priority To provide an estate and IT infrastructure that is safe, modern and fit for purpose. Trust Indicators 1. All premises will achieve at least 4 stars against our 5 star environmental standards % of our people will describe IT response times as good or very good Performance 1. All premises will achieve at least 4 stars against our 5 star environmental standards During the year, the 5 Star standards were developed to assess the safety and suitability of our environment and equipment. The 5 star standards incorporated requirements around infection control, cleanliness, privacy and dignity. Wards have to score 100% to be awarded a star against each of the five domains. The 5 star standards were later incorporated into the InCA assessment process (see notes in Priority 1.2.1). The scores are collected as part of our quality dashboard. Scores throughout the year show that all of our 21 wards have achieved at least 4 stars during the period. We continue to monitor our performance on this indicator regularly through our quality dashboards to ensure that issues are identified and acted upon in a timely manner. This shows our commitment to maintaining the quality of our environment and equipment to protect the safety of our patients, visitors and staff. Quality improvement Environmental work was undertaken in all of our inpatient units throughout the year particularly focusing on the removal of ligature points, reinforcing our doors and windows, making our wards compliant with Same Sex Accommodation standards and overall redecoration and refurbishment. Outside, entrances to the wards were improved, fences were raised and benches secured, among others. Environmental work has now been rolled out to our community premises % of our people will describe IT response times as good or very good Data for this indicator is collected through our staff Pulse Surveys which appears on the computer screens when staff log on. As of March 2013, the total average scores across the three Divisions show that only 43% of staff rate IT response times as good or very good. Actions taken Further work will be undertaken to determine the specific areas of performance that staff are not happy about. Discussions are being held with SERCO, our IT service provider, in order to address these areas and ensure improvement of staff satisfaction scores around IT response time. This has been carried forward as our quality priority for 2013/14. Page 10 of 66 Draft May2013/WLlaneza

152 1.2.3 PRIORITY 3: CLINICAL EFFECTIVENESS 2012/13 Priority To provide services through empowered staff with the right skills, attitudes and behaviours. Trust Indicators 1. 85% of our people will state that they are able to make the changes that they feel necessary for excellent patient care. 2. We will achieve the national upper 20% in the number of our people who state that they will recommend CPFT to family and friends as a place of work % of our people will have completed all their mandatory training. 4. No more than 5% of inpatient shifts will have temporary staff greater than 20% of all staff on that shift. Performance 1. 85% of our people will state that they are able to make the changes that they feel necessary for excellent patient care. Data for this indicator is collected through our staff Pulse Surveys and scores are reported through our quality dashboards. Trust scores for 2012/13 show that, on average, only 46% of staff stated that they are able to make changes necessary for excellent patient care. We are introducing a range of quality improvement initiatives to promote and support staff engagement and involvement in matters that are important to patient care as part of our Big Conversation programme. These are outlined section 5 of this report (Workforce Factors). Actions for this indicator are linked to the Trust National Staff Survey action plan which includes developing a Workforce Strategy in consultation with staff (see section 5). 2. We will achieve the national upper 20% in the number of our people who state that they will recommend CPFT to family and friends as a place of work. The 2012 National NHS Staff Survey results show that CPFT is in the bottom quartile when compared to similar Trusts for the percentage of our staff who would recommend CPFT to family and friends as a place of work, scoring 33% (against the national average of 53%) compared to 48% in Data from our own internal Pulse Surveys is currently showing a much higher score of 48% as of March We recognise that this is largely due to the challenges faced by our staff in the past year as part of the quality turnaround programme. We are introducing a range of improvement initiatives to improve the experience of our staff through our Big Conversation programme which is outlined in section 5 (Workforce Factors). However, we acknowledge that we have a lot to do improve the way our staff feel about their work and CPFT. Actions for this indicator are linked to the Trust National Staff Survey action plan (see section 5) Our commitment to our staff is reflected in our Quality Diamond Strategy (Objective 2) and this measure has been carried forward as our quality priority for 2013/14. Page 11 of 66 Draft May2013/WLlaneza

153 3. 95% of our people will have completed all their mandatory training. As of March 2013, overall mandatory training stands at 85%, as follows: 94% for mandatory gateway E-learning 82% for mandatory physical skills modules 80% for mandatory clinical skills modules Performance against this indicator is reported through our quality dashboards. Although falling short of the 95% target that we have set ourselves, this represents a significant improvement over 68% in 2011/12. A Project Group was formed during the year to drive achievement of this target. This has been continued in 2013/14 to ensure continued improvements. 4. No more than 5% of inpatient shifts will have temporary staff greater than 20% of all staff on that shift. Ensuring that our wards have the right staffing levels with the right skills is a priority of the Trust, and our commitment to achieving this is embedded in Objective 2 of our Quality Diamond Strategy. During the year this indicator was reviewed and revised and is now reported in our quality dashboard as the percentage of bank and agency shifts used as a proportion of total shifts on the ward. As of March 2013, this came to 24.70% which is significantly over our target of 5% This remains a priority of the Trust and is monitored through our quality dashboards. We have undertaken a major review of inpatient and community establishments during 2012 including the use of temporary staff through the PET Project (see below). The implementation of the findings of this review will ensure that the use of temporary staff will reduce to 5% by mid 2013/14 PET (Productivity, Establishment & Temporary Staff) Project The PET project was established in January 2013 following a detailed review of ward establishments and use of temporary staff in late There are three key work streams in Phase 1 which is due to be completed in September 2013: Work stream 1: Delivering the new 333 staffing establishment model. This is currently being rolled out in selected inpatient units in the Cambridge area. Work stream 2: Making operational changes. This includes looking at shift pattern changes, eradicating restrictive shift patterns, absence management and looking at areas where productivity can be improved (e.g. administrative support and introduction of the RiO electronic patients records system). Work stream 3: This looks at the performance and effective sourcing of bank staff and effective utilisation of MAPS, our electronic rostering system. Phase 2 focuses on productivity and new ways of working and is planned to be completed by March 2014 Page 12 of 66 Draft May2013/WLlaneza

154 Clinical Effectiveness Patient Safety Patient Experience 2010/ REVIEW OF QUALITY PRIORITIES SET IN PREVIOUS YEARS In this section, we look back at the priorities we set in 2010/11 and 2011/12 and provide an update on progress made to March This allows us to show how we continue to measure, maintain and develop these areas even when new priorities become the focus of improvement. As of March 2013, we have met three out of six of our quality priorities and partially met three from 2010/11, and we have met five out of six quality priorities and partially met one from 2011/12. These are outlined below. Quality Priority Update on Progress as of March 2012/13 Priority 1 Improvement in annual Patient Survey responses for overall satisfaction rating Priority 2 Ensure 95% of patients have a care plan Priority 3 Reduce all suicide by patients in contact with secondary mental health services by 20% by 2013 Priority 4 Reduce the number of physical assaults within secondary mental health services by 20% by 2013 Priority 5 Compliance with 18 week referral to treatment waiting time target Priority 6 Ensure that 95% of CPA patients have a HoNOS outcome assessment in a 12 month period Results of our annual National Community Patient Survey show an overall improvement in our scores for 2012 and an improving trend over time (see section for further details). This remains a Trust priority and is reported in Part 3 of this Quality Report. We have consistently achieved this target over the last three years. In 2012/13, we changed the focus to improving the quality of our care plans which we have also achieved (see sections and for further details). This remains a Trust priority and is reported in Part 3 of this Quality Report and monitored throughout the year through our quality dashboard. Data available as of March 2013 shows an 11% reduction between 2010/11 and 2012/13 in the total number of deaths with a verdict of suicide and probable suicides, where the verdict was misadventure, accidental death, cause unknown/unexpected, or cases where we have not yet received a verdict from the coroner. This remains a Trust priority, and we have commissioned an independent review of inpatient Serious Incidents (SIs) by Professor Louis Appleby from Manchester University to help us identify the areas where we can make further improvements. As of March 2013 there was an 11% reduction between 2010/11 and 2012/13 in the total number of physical assaults reported. This remains a Trust priority and we have improved our training on the assessment and management of violence and aggression. We will continue to monitor this through our quality dashboard. Although our children s community services had breaches in two of their services, the Trust s overall average referral to treatment time was 1.97 weeks as of March 2013 compared to 4.08 weeks in 2011/12. This remains a Trust priority and is reported through our quality dashboard. As of March 2013, 85% of CPA patients had a HoNOS assessment. This remains a Trust priority and we are addressing the issues around the electronic Mental Health Clustering Tool (MHCT) and our electronic Clinical Documents Library (CDL) system. This is reported through our quality dashboards. Page 13 of 66 Draft May2013/WLlaneza

155 Clinical Effectiveness Patent Safety Patient Experience 2011/12 Quality Priority Update on Progress as of March 2012/13 Priority 1 To develop routine patient feedback mechanisms across all care pathways Priority 2 To develop and implement a Carer Strategy Priority 3 To establish with primary care a Suicide Prevention Strategy Priority 4 Reduce the risk of absconsion through a review of clinical risk assessment, observations, access and therapeutic programmes Priority 5 Significantly strengthening patient safety training in adult safeguarding, clinical risk assessments and physical interventions Priority 6 To develop and implement a consistent recovery outcome measure which involves service users directly in planning their care Meridian, the IT solution to collect patient experience information, was rolled out to inpatient teams in January 2012 and community teams in April Routine patient feedback is collected using an ipad every month and results are reported as part of the quality dashboards. This remains a Trust priority and is reported in Part 3 of our Quality Report (see sections & 4.1.4). The Partnerships Strategy was developed during the year and is due to be approved in May This will drive forward our approach to develop and improve the way we inform, consult, listen, involve and empower people involved in our services. This remains a Trust priority moving forward. Within the region, Public Health England is leading on the suicide prevention agenda and is in the process of developing a regional Suicide Prevention Strategy. The Trust is a member of the Joint Countywide Suicide Prevention Group. CPFT is currently developing its own Suicide Prevention Strategy, ensuring that this links with the Public Health agenda and reflects the national strategy. This is due to be ratified in May This remains a Trust priority and will be reported in Part 3 of the Patient Safety section of future Quality Reports. We have put measures in place such as improving our clinical risk assessment training, developing a policy and improving arrangements around access to our wards, carrying out environmental work, which includes reinforcing doors and windows, raising the height of garden walls and moving garden benches away from the garden walls, among others. These measures have resulted in a 10% reduction in the number of absconsions between 2011/12 and 2012/13. This remains a Trust priority and is reported through our quality dashboard. Although we have just missed the target of 95% as of March 2013, compliance rates in mandatory training is much improved and we are only slightly below our agreed target. This remains a Trust priority and is reported through our quality dashboard. We have introduced measures to support this objective, such as the introduction of the HoNOS outcome scales, strengthening collaborative care planning and the involvement of patients and carers in planning their care through the development of 7Cs standards. We are now working with Clinical Divisions to help them identify Patients Reported Outcome Measures (PROMs) that are specific to their services and the needs of their patient group. These will be incorporated into their Divisional quality dashboards. Page 14 of 66 Draft May2013/WLlaneza

156 1.4 QUALITY PRIORITIES FOR 2013/14 The priorities for quality improvement for 2013/14, outlined below, have been developed as a result of the following: We have listened to feedback from our patients and their families, our staff, our commissioners, governors, regulators and other stakeholders. We have reviewed information from various sources such as PALS and Complaints, patient and staff surveys, serious incidents, incidents and near misses, clinical audits, research, service development projects and external service reviews. We commissioned PwC (PricewaterhouseCoopers) to review our systems to support effective quality governance within the Trust. Please refer to the summary of our Quality Diamond Strategy in Annex 1 for additional details on the improvement initiatives PATIENT EXPERIENCE Priority 1: To improve the experience of our patients and our staff. 1 65% of our patients will be happy to recommend our services to their family and friends 2 60% of our staff will recommend CPFT to care for their friends and family 3 60% of our staff will recommend CPFT to family and friends as a good place to work Rationale for Inclusion We believe that a basic indicator of quality is when people are happy to recommend a product or a service to their family and friends. We have chosen these indicators as our Net Promoter Score (NPS), in conjunction with the Department of Health (DH) guidance. We believe that if our patients and staff are happy to recommend our services to their family and friends then this means that they are happy with the quality of the care and services that they are receiving and providing. We also believe that there is a strong correlation between staff satisfaction and patient satisfaction. If our staff believe that they are respected, valued and supported, this will have a direct impact on the quality of their interaction with our patients and the care that they provide. Measurement Data for these indicators will be taken from our internal monthly patient satisfaction survey and staff Pulse Survey, triangulated against the national patient and staff surveys. Improvement initiatives Patient experience Develop Care Pathway services Implement year 1 action plan from Engagement Strategy Continue to roll out our Recovery College East Develop a new Social Care Strategy Implement Big Conversation initiatives Staff experience Continue to roll out the CPFT Academy To continue with the Quality Heroes and Team Champions initiative Continue to strengthen staff communication (e.g., Webex sessions, Town Hall events& Diamond Talkback) Implement Big Conversation initiatives Monitoring and Reporting Monthly quality dashboard reporting, Divisional Performance Review meetings and regular reporting to Quality & Performance Committee and the Trust Board. Page 15 of 66 Draft May2013/WLlaneza

157 1.4.2 PATIENT SAFETY PRIORITY 2: To strengthen the culture of safety in CPFT 1 Our teams will achieve a Trust wide average InCA score of 95% by Qtr4 of 2013/ % of our people will complete safeguarding adults and safeguarding children training 3 65% of our people will describe IT response times as good or very good Rationale for Inclusion The quality of assessments, risk assessments and care planning have a direct impact on the provision of safe and effective care. The standards around these are embedded in InCA which is used to assess the performance of our clinical teams. InCA also covers all 16 CQC outcomes which include standards around premises and equipment, safeguarding and safety, cleanliness and infection control, among others. Compliance with these standards will help us ensure the safety and wellbeing of our patients, visitors and staff. Providing quality service is dependent upon having staff with the right skills, knowledge and experience, and providing them with appropriate systems and processes. Safeguarding training is mandatory and as of March 2013, our compliance rates are 94% for safeguarding adults and 88% for safeguarding children. We need to improve on these compliance rates to ensure that our staff know how to recognise and act appropriately when they observe safeguarding incidents. Finally, we need to ensure that our staff have the information that they need in a timely manner to provide safe and effective care. This is dependent upon having IT systems that are appropriate, responsive and fit for purpose. Measurement Data for these indicators will be taken from monthly InCA assessments, quality dashboards, incident reporting and staff Pulse Surveys. Improvement initiatives Regular review of the InCA assessment tool and process, development of servicespecific standards and roll out to the rest of our community-based services. Pilot the No Force First initiative in selected inpatient services Roll out of RiO, our electronic clinical records system, to the rest of the Trust. Monitoring and Reporting Monthly quality dashboard reporting, Modern Matrons meetings, Divisional Performance Review meetings and regular reporting to the Clinical Executive, Quality & Performance Committee and the Trust Board. Page 16 of 66 Draft May2013/WLlaneza

158 1.4.3 CLINICAL EFFECTIVENESS PRIORITY 3: To improve outcomes of care for our patients 1 98% of relevant admissions to our acute wards are gatekept by Crisis Resolution Home Treatment Teams (CRHTT) 2 Achieve the 60% national target across all three IAPT services for the proportion of people referred for psychological therapy who receive psychological therapy. 3 Improve the physical health outcomes for our patients Rationale for Inclusion Assessment by the CRHTT prior to admission into acute inpatient units ensures that only patients who need inpatient care are admitted into our wards and that the patient has the most appropriate plan of care agreed by all relevant parties, including the patient. As of March 2013, our internal reports show that 95% of patients admitted to CPFT inpatient units were assessed by CRHTT. Data reported by the Health and Social Care Information Centre (HSCIC) as of December 2012 shows the national average at 98% with 29% (n=18) of mental health Trusts achieving 100% compliance. We need to improve on this performance. NICE guidance and quality standards recommend the use of psychological therapies for the treatment of psychological disorders either on its own or alongside traditional medication. The Department of Health has promoted the use of psychological therapies through the establishment of IAPT (Improving Access to Psychological Therapies) services. As of March 2013, not all of our IAPT services met the national 60% target for the proportion of our patients referred for psychological therapy who receive psychological therapy. We need to achieve this target across the Trust. A high level scoping of physical health monitoring in CPFT shows that we need to improve our arrangements in this area. This is supported by findings from national and local audits. This is also a CQUIN target for 2013/14 covering inpatient services.. Measurement For priorities 1 and 2, data will be taken from the quality dashboards and contractual performance reports. In regards to the physical health priority, we will review the existing policies on physical health (inpatient and community) and develop an inclusive Physical Health Policy. develop a Physical Health dashboard. This will provide us with baseline information from which we can set improvement targets for 2014/15. Improvement Initiatives Review and update the Psychological Therapies Strategy Review the referral process and pathway into care across all three IAPT services to streamline the process and achieve consistency across the Trust. Trust wide review of Physical Health monitoring arrangements (new project) to identify gaps and develop appropriate actions. Develop Physical Health Policy, Physical Health dashboard and improve training around physical health for frontline staff Monitoring and Reporting Monthly quality dashboard reporting, Divisional Performance Review meetings and regular reporting to the Clinical Executive, Quality & Performance Committee and the Trust Board. 1.5 HOW WE WILL MONITOR THESE PRIORITIES Page 17 of 66 Draft May2013/WLlaneza

159 We reviewed our governance structure based on recommendations from PwC to strengthen the quality governance arrangements in the Trust. The new governance framework, which will provide assurance that the Trust is meeting our strategic objectives and priorities, was approved by our Board of Directors in February ASSURANCE AT TRUST LEVEL The governance committee structure responsible for monitoring our Trust s objectives and priorities is outlined below. Board of Directors Audit & Assurance Committee Quality & Performance Committee Patient Safety, Risk & Experience Group Clinical Effectiveness Group Research & Development Group Performance & Risk Executive Finance Executive Clinical Executive Executive Management Group Mental Health Legislation Group Workforce Executive Professional Development & Education Group The Audit & Assurance Committee and the Quality and Performance Committee have the primary responsibility for obtaining assurance, on behalf of the Trust Board, that the Trust is discharging its duties properly and that it is meeting its strategic objectives. The Executive Management Group is chaired by the Chief Executive and has an operational management responsibility for the Executive committees, which are responsible for reviewing and making recommendations on the strategic direction of the Trust. The Quality & Performance Committee is the main Board subcommittee responsible for monitoring our compliance against the quality improvement priorities throughout the year through position summaries on a regular basis. It will also inform the Board of our delivery against these priorities alongside the regular reports on the Divisional quality dashboards to provide assurance of continued improvements in the delivery of care across the Trust ASSURANCE AT OPERATIONAL LEVEL Clinical and integrated governance has its foundations on having effective processes at team level. We believe that patient and staff relationship lies at the heart of improving quality. We therefore see governance as a pyramid based on the quality of interaction between our staff and our patients. This is supported by robust governance processes and a dynamic performance management framework at Divisional level. Page 18 of 66 Draft May2013/WLlaneza

160 Within this governance framework, we have introduced a set of standards for team governance which is known as how are we doing? meetings. The standards are outlined below. Team Governance Framework The purpose of team governance is to ensure and improve the quality of patient and carer experience, patient safety and to identify, mitigate or escalate the risks to the delivery of this. Team governance will follow the five steps of governance process, from patient experience through to monitoring progress. Team governance should take place in a spirit of openness, constructive challenge and willingness to reflect and learn. They shouldn t be afraid to raise risks and issues if they don t believe they can manage this. 4 Teams must produce a governance report once a year Team governance meetings will take place at least monthly and can either be stand alone meetings or form part of multi-disciplinary team meetings with protected time for governance. Team governance processes will be multi-disciplinary and include representatives of all staff groups, this includes administrative and housekeepers as well as health and social care professionals. Teams will discuss and agree how patients and carers are involved in their governance processes. We will provide teams with the necessary training, support and practical tools to help them undertake these meetings effectively. This will include: provision of relevant and timely information to help them make decisions and develop appropriate actions self-assessment and peer review tools such as the InCA which provides teams with the basis from which they can evaluate their compliance with the CQC essential standards establishing a new process and system of risk management which will form the backbone of governance within the organisation, through the development and maintenance of team risk registers that will feed into the Divisional and Board Assurance Framework (BAF). Divisional Governance Framework We have introduced Divisional Accountability Governance Agreements (DAGA) which are designed to clearly set out the expectations of the Board of Directors in regard to both quality, safety and risk management arrangements as well as financial performance. This will encompass the following processes: Each Division will have monthly reviews through the Performance and Risk Executive which considers all aspects of performance, risk management and service planning. Divisions will be required to hold internal governance meetings to look at team governance and specific safety, quality and effectiveness issues. This will include reports about their compliance with the CQC essential standards through the InCA process, risks identified at team level, incident reports and complaints. Both team and Divisional governance frameworks will feed into and provide assurance to the Trust Board that we are meeting our objectives and quality priorities. Page 19 of 66 Draft May2013/WLlaneza

161 2.0 STATEMENT OF ASSURANCE 2.1 REVIEW OF SERVICES Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) is a partnership organisation providing mental health and specialist learning disability services across Cambridgeshire and Peterborough, and also children's community services in Peterborough. We are a teaching Trust and work with the Department of Psychiatry at the University of Cambridge. CPFT is also a member of Cambridge University Health Partners (CUHP), one of only five Academic Health Science Centres in England. The Trust provides the following: Children s mental health and community services; Adult mental health services; Older people s mental health services; Primary care therapy and liaison psychiatry services; Forensic and specialist mental health services; Substance misuse services; and Specialist learning disability services. We also provide some specialist services on a regional and national basis. Full details of our services are available on the Trust Website. Community learning disability services are provided by the Cambridgeshire Learning Disability Partnership and the Peterborough Learning Disability Partnership. Inpatient intensive assessment and support services are provided by the Trust in collaboration with the Learning Disability Partnerships. Around 2,000 staff working across over 75 sites in Cambridge, Huntingdon, Peterborough, Fenland, Mid Essex and Norfolk. Three Clinical Divisions o Acute Care Services o Community Services o Specialist Services Our partners include: o Cambridgeshire County Council o Peterborough City Council o NHS Cambridgeshire o NHS Peterborough Note: The new CCGs (Clinical Commissioning Groups) replaced NHS Cambridgeshire and NHS Peterborough in April During 2012/13 CPFT provided and/or sub-contracted NHS services in seven relevant health services (outlined above): The Trust has reviewed all the data available to us on the quality of care in all seven of these relevant health services. The income generated by the relevant health services reviewed in 2012/13 represents 100% of the total income generated from the provision of NHS services by CPFT for 2012/ PARTICIPATION IN CLINICAL AUDITS During 2012/13, two national clinical audits and one national confidential enquiry covered relevant health services that CPFT provides. During 2012/13 CPFT participated in 100% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that CPFT was eligible to participate in during 2012/13 are as follows: Page 20 of 66 Draft May2013/WLlaneza

162 Prescribing Observatory for Mental Health (POMH) National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental illness (NCI/NCISH) National Audit of Psychological Therapies (NAPT) The national clinical audits and national confidential inquiries that CPFT participated in, and for which data collection was completed during 2012/13, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or inquiry. Table 2: National audits that CPFT participated in during 2012/13 Audit % Cases submitted University of Manchester National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) 20 questionnaires sent by NCISH between April 2012 and March 2013, 20 completed and submitted by CPFT (100%) 3 homicide questionnaires sent (2 in March 2013 so not yet due at time of report) and 1 completed and submitted by CPFT (100%) National Programme of Prescribing Observatory for Mental Health (POMH) POMH-UK 1f & 3f Prescribing highdose and combination antipsychotics: acute/picu, rehabilitation/complex needs, and forensic psychiatric services. POMH-UK 2f: Screening for metabolic side effects of antipsychotic drugs POMH-UK 11b: Prescribing antipsychotic medication for people with dementia POMH-UK 12a: Prescribing for people with personality disorder Royal College of Physicians National Audit of Psychological Therapies 7 participating teams 79 questionnaires submitted 7 participating teams 105 questionnaires submitted 11 participating teams 169 questionnaires submitted 13 participating teams 77 questionnaires 74 Service user questionnaires returned, 82 case note audit cases submitted and 28 therapist questionnaires returned. The reports of six national clinical audits were reviewed by the provider in 2012/13. These are: a) Prescribing Observatory for Mental Health (POMH) audits POMH-UK 1f: Prescribing high dose & combined antipsychotics in Adult in acute adult inpatient or psychiatric intensive care wards POMH-UK 2f: Screening for metabolic side effects of antipsychotic drugs POMH-UK 3f: Prescribing high dose and combined antipsychotics in Forensic wards POMH-UK 11b: Prescribing antipsychotic medication for people with dementia POMH-UK 12a: Prescribing for people with personality disorder b) National Audit of Schizophrenia and CPFT intends to take the following actions to improve the quality of healthcare provided. Page 21 of 66 Draft May2013/WLlaneza

163 Develop a Medication & Physical Health Dashboard to drive up standards in prescribing and physical health monitoring Review existing guidelines and procedures for poly pharmacy and prescribing over BNF limits to ensure clarity of procedures and requirements. Develop a Trust wide tool to record the history of prescribed interventions (medication, psychological therapies and other interventions), to include documentation of side-effects and benefits Add a standard line in the standard letter to the GP which is sent prior to a care review requesting information about physical health investigations and most recent list of prescribed medication. Review the protocol about whether psychological treatments should be prioritised for patients with treatment resistant schizophrenia as opposed to first episode or both. Develop a register to record all deaths in any age (to include age at death, ICD10 diagnoses, MH cluster. and causes of death) to create a data set that will inform future service developments. Disseminate results of the Shimme Project (Shared decision making in medicines management) when completed and ensure that learning around shared decisionmaking in medicines management is shared and implemented in practice. An identified Trust staff will link with Cambridge University Department of Public Health to promote research on diabetes in people with mental disorder The reports of 24 local clinical audits were reviewed by the provider in 2012/13 and CPFT has taken/intends to take the following actions to improve the quality of healthcare provided: 1. Standards and quality of documentation and record keeping Form a Task & Finish Group to review and develop clear and specific guidance on the practice and requirements around record keeping and documentation. Review the Clinical Record Keeping Policy to clarify standards of practice and procedures around competency assessments and countersigning delegation Include the assessment of competence for record keeping in the Trust competency framework for non-qualified staff Compile all Trust approved forms and make these accessible on the Trust intranet 2. Medications management Update the Medication Competency Workbook to include the need to document the reason for administering the PRN (as required) medication and the outcome of the PRN Add information about what is a rapid tranquilisation and the monitoring requirements following rapid tranquilisation in the Medication Competency Workbook Include examples of medicines reconciliation in the activity section of the medicines management training for nurses 3. Review of policy and procedures Review the Discharge Policy and clarify procedures around discharge planning and documentation requirements Review the Section 17 Policy and clarify the procedures particularly in relation to the responsibility of the nurse in charge to ensure that a risk assessment is carried out prior to allowing the patient to leave the ward for an agreed leave, reviewing planned leave with the patient, and the required documentation regarding these areas Review the forms currently attached to the Falls Policy: (Falls screen, Falls assessment, & Post-falls checklist) to clarify requirements for documentation Page 22 of 66 Draft May2013/WLlaneza

164 Revise the risk assessment section in the Safeguarding Adults Policy to include agreed timescales for completion of investigation, emphasise requirement for correct filing of documentation, and include requirement for the checklist to be signed off. Develop a pro-forma to guide doctors on the completion of In-patient and CTO (Community Treatment Order) reports. Develop a Trust DoL (Deprivation of Liberty) policy to replace the DoLs guidelines and develop a robust implementation plan. Review the Mental Capacity Act Policy and redesign the CPA capacity form replacing text requirements with tick boxes where possible, and to reduce the length of the form by replacing the legal language with plain English. Revise Medicines Policy to include explicit requirement to document discussion about side effects and benefits of medication Develop a Trust policy on the procedures and standards for Advance Directives Review and update the Continence Policy. Following implementation of actions from audits completed in 2011/12, improvements were made in the quality of our services in 2012/13. Examples include: 1. Medicines management The action to develop and pilot a new form to record discussions about new medication with patients and carers in Phoenix ward has been successful and is reported to have improved engagement and information support for patients and carers. (POMH10a: antipsychotic medicine in CAMH audit) A Medication Competency Workbook was adapted from a London-based Trust and attached to the Medicines Policy to provide clear guidance to nursing on medicines administration, review and documentation. This has made demonstrable improvements on medicines management practice in the wards (Omission of Prescribed drugs audit). The following actions were implemented following the POMH11b: prescribing antipsychotic medication for people with dementia audit, and have resulted in improved results for the 2012/13 round of the audit. o Development of CPFT-specific guidelines which specifies that all letters to GPs for patients with dementia with an antipsychotic medication initiated by the Trust should have an instructions to GPs to review the medication within 6 weeks o Development of joint guidelines on the use of antipsychotics for BPSD (Bipolar Spectrum Disorder) across primary and secondary care which included recommendations for appropriate documentations for appropriate documentation and review dates of medication. 2. Practice improvement Various improvements were implemented from findings of the Record Keeping team-based monitoring audits. This included: o In the Peterborough child health community services, making modifications to Systm1 (electronic records system) to improve processes around countersigning entries made by non-qualified staff, recording of ethnicity data and recording diagnosis and needs at the point of referral. o In the IAPT services, development of guidance around documentation practice requirements and completion of risk assessments, among others. CG45: Antenatal & postnatal mental health audit o A new specialist mental health midwife has been appointed in The Rosie (maternity hospital in Addenbrookes) following results of the audit. Joint planning meetings are held regularly with adult mental health services to coordinate pre birth planning meetings for women Page 23 of 66 Draft May2013/WLlaneza

165 3. Policy/guidance development The Use of Physical Interventions in the Management of Violence & Aggression Within Mental Health & Learning Disability Policy was reviewed and updated to clearly specify the requirement for documentation around physical restrain (NICE CG25: Violence audit). A Perinatal Standard Operating Procedure was developed to provide staff with guidance on the safe management of women with serious mental illness (SMI) or at significant risk of relapse of SMI in the perinatal period (CG45: Antenatal & postnatal mental health audit) Consent forms for Children s services were revised and incorporated in the Consent Policy (Children Act 1989 Consent to treatment audit in Phoenix ward) and arrangements put in place to make copies of Consent forms easily accessible to staff. The Reading of Rights form was amended to evidence informing patients of their rights to see an IMHA (Independent Mental Health Advocate Audit) 2.3 PARTICIPATION IN CLINICAL RESEARCH RESEARCH AND DEVELOPMENT (R&D) Participation in clinical research demonstrates the Trust s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. CPFT is the host for the National Institute for Health Research (NIHR) Mental Health Research Network that supports well designed research studies adopted to the UK Clinical Research Network (UKCRN) portfolio. The number of patients receiving relevant health services provided or sub-contracted by CPFT in 2012/13 that were recruited during that period to participate in research approved by a research ethics committee was This surpasses the Trust s target of 800 for the year which is positive progress. It is expected that the results for the year will inform the Trust s financial allocation from the Comprehensive Local Research Network (CLRN) for 2013/14 enabling re-investment in Trust research programmes. As of March 2013, there were 105 active studies in the Trust of which 69 were adopted on the NIHR portfolio. There were 10 portfolio studies in set up. A total of 37 studies were approved in 2012/13, and there are a further 30 studies currently seeking Trust approval. Examples of quality improvement actions relating from research include: CRIS database: CPFT has ethical approval to establish a research database (Case Registry Interactive Search) that will facilitate recruitment of participants into research studies and pilot work is on going DeNDRoN (Dementias and Neurodegenerative Diseases Research Network): New team base and research facility has been launched in December in Windsor House, Fulbourn MHRN (Mental Health Research Network) A transition plan has been developed by the Department of Health that will bring about key changes for the current set up of the NIHR Clinical Research Network (CRN). By April 2014 the NIHR CRN will comprise of 15 Local Clinical Research Networks, each with a single host organisation. The appropriate host organisations will be confirmed by Autumn 2013 through NHS competition. The boundaries of the networks have yet to be decided but they will align with the Academic Health Science Networks. Page 24 of 66 Draft May2013/WLlaneza

166 2.3.2 CLAHRC CP CPFT is also the lead NHS Trust for the NIHR Collaboration for Leadership in Applied Health Research and Care for Cambridgeshire and Peterborough (CLAHRC CP), a centre for mental health research that will accelerate health research into patient care. As of March 2013, CLAHRC CP had over 100 projects on its portfolio, 23 of which were classed as priority projects, across the five themes: Adults, Child and Adolescent, Old Age and End of Life Care, Public Health and Design and Implementation. Examples of CLAHRC studies that have led to improved outcomes of care include: Transfer of Care at 17 pilot study Strong collaborations and partnerships with NHS and social care partners have ensured findings from this study, which focuses on the transition period from adolescent to adulthood, have been incorporated into care pathways. Dementia register The Old Age theme has conducted a scoping exercise on the feasibility of establishing a dementia register in Cambridgeshire and the project is being taken forward by the NIHR Biomedical Research Centre (BRC). Cognitive therapies The East of England SHA has adopted the research outputs of an NIHR CLAHRC CP project on the comparative effectiveness of cognitive therapies delivered face to face and over the telephone in the Improving Access to Psychological Therapies (IAPT) programme. The outcome of which is that regional training for telephone sessions has been delivered. The NIHR CLAHRC CP has continued to produce a successful Fellowship Scheme over the past two years involving 3 cohorts, 33 professionals and 14 partner organisations. Findings from several fellows projects have been translated into service change and resulted in published journal articles. An example of service change is the introduction of training for District Nurses in evidence-based end of life care in Peterborough SERVICE USER AND CARER ENGAGEMENT IN RESEARCH Service User and Carer Involvement is a key priority area within the Trust s R&D activities. The R&D department runs a programme to support and strengthen meaningful involvement of Experts by Experience in all stages of the research. This service is available to all potential and established NHS researchers, service users and carers. During 2012/13 we recruited and supported 18 service users and carers to be involved in 11 research activities as service user advisors or researchers. Advice and support was provided to 15 researchers. Key achievements during the year include: Development of a pilot introductory research training for new members of our service user and carer group in collaboration with CLAHRC CP. The programme provides a basic introduction to research and involvement in research. Nine people attended the first training course in March 2013 with very positive feedback. Since September 2012 service user and carer involvement has become a step in the process of obtaining CPFT R&D approval. As of March 2013, 80% of all locally developed research projects that have gone through R&D approval have been reviewed by members of our service user and carer research group to ensure that their project has appropriate service user and carer involvement. Page 25 of 66 Draft May2013/WLlaneza

167 2.4 COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN) PAYMENT FRAMEWORK A proportion of CPFT s income in 2012/13 was conditional upon achieving quality improvement and innovation goals agreed between CPFT 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 online at: internet link will need to be inserted here. The total value of the payment for completion of our quality goals in 2012/13 amounts to 1,345,282 compared to 1,364,674 for our 2011/12 CQUIN. The Trust s Lead Commissioner is NHS Cambridgeshire with whom the Trust agreed a number of quality goals for 2012/13. It is worth noting that the goals agreed at the beginning of 2012/13 as reported in our Quality Report 2011/12 were further reviewed and finalised in July These are outlined below: Table 3: CQUIN performance against 2012/13 goals CQUIN 2012/13 GOALS Goal 1 Theme: NHS Safety Thermometer Improve collection of data in relation to pressure ulcers, falls, urinary tract infection with a catheter, and VTE. Goal 2 Theme: Dementia Improve awareness and diagnosis of dementia by training staff in other local NHS providers. Indicator 1 Number of dementia training sessions delivered to each Provider Trust highlighted above to enable these service Providers to deliver their provider specific CQUIN schemes relating to dementia. Performance The Trust has carried out monthly NHS Safety Thermometer surveys of wards for older people and learning disabilities. Quarter 1: Achieved 97.6% harm free care Quarter 2: Achieved 98.8% harm free care Quarter 3: Achieved 97.1% harm free care Quarter 4: Achieved 98.2% harm free care Indicator 1 The Trust has, in collaboration with all Acute Providers within the locality, developed and implemented over 70 training sessions. Key outcomes: Feedback received shows that 95% of participants learnt lot about the subject as a result of the training 86% of participants reported a change in their attitude and approach to people with dementia. Indicator 2 Improve access to prompt advice and support for people and their carers recently diagnosed or identified as potentially at risk of dementia following screening in hospital or community services. Goal 3 Theme: Patient experience Improve responsiveness to personal needs of patients. Indicator 1 To ensure that providers have real time systems in place to monitor patient experience. Indicator 2 There is initial evidence to show that referrals to Liaison Services within CUHFT (Cambridge University Hospitals NHS Foundation Trust) have increased as a result of the training. Indicator 1 CPFT has developed, with Meridian, a web based patient survey system to routinely collect real-time patient experience data across all inpatient and community teams using ipads. Results are discussed at our monthly Divisional Performance Review meetings with clear lines of accountability up to the Trust Board Page 26 of 66 Draft May2013/WLlaneza

168 Indicator 2 To demonstrate improvements in patient experience using the Net Promoter Score (NPS). Goal 4 Theme: Making Every Experience Count Clinical Staff working in the agreed areas have appropriate knowledge and skills to make to make a brief advice intervention for alcohol/smoking or both and to signpost or refer as appropriate in line with the Making Every Contact Count Initiative. Goal 5 Theme: Measuring Outcomes Routine reporting of outcome measures for each of CAMH (IAPT), Adult (Recovery Star) and OPMH CORE 10 and QALY AD. Goal 6 Theme: Perinatal Mental Health Delivery of NICE guidelines for priority access to IAPT for pregnant and postnatal women. Goal 7 Theme: Learning disability Improve access to mental health services for people with learning disability, based upon the annual selfassessment of progress that CPFT has completed and reinforcing the subsequent Action Plan. Goal 8 Theme: ADHD Training of core staff within Intake and Treatment Teams in diagnosis and advice on patient management for ADHD. Indicator 2 The Trust s overall average NPS score of 47% for the year. This shows a 13% increase from the baseline figure in April We provide an e-learning training package to our staff within the Rehabilitation and Recovery Pathway to equip them with the knowledge and skills to engage with their patients around healthy lifestyle issues and refer them on to the appropriate agency, where required. We have not met the target as of March 2013 The Trust will continue to roll out the e-learning package to the remainder of staff in early 13/14. CAMH IAPT: Our staff have been trained in undertaking the CYP-IAPT Outcomes Measures during 12/13. We encountered a number of challenges around putting the technology in place but by Q4 the necessary systems were in place to support greater usage of outcomes measures in 2013/14. Adult: During 2012/13 we trained over 80% of our staff within the Rehabilitation and Recovery Pathway to use the Recovery Star which gets a patient to look at recovery as a journey with different stages. Using this approach has led to a change in the culture, care delivered and supporting documentation resulting in better outcomes for the patient. OPMH CORE 10/QALY AD: 70% of service users in the specified pathways have undertaken the specified outcome measures. As per the NICE Guidelines we give priority access to perinatal patients with the average waiting time across the locality being 25 days during 2012/13. The Trust has continued to deliver against the Learning Disability Performance Indicators Access to Healthcare Action Plan. CPFT staff have delivered ADHD training to staff within the Department of Psychiatry and the Intake and Treatment Team during 2012/13, based on training materials developed through CPFT and the University. Page 27 of 66 Draft May2013/WLlaneza

169 2.5 CQUIN GOALS 2013/14 As part of our contractual agreement with NHS Cambridgeshire for 2013/14, the Trust will work towards the achievement of a range of quality goals which will support further improvements in patient experience, patient safety and clinical effectiveness. We will report on our achievements in meeting these goals as part of next year s quality report. The proposed goals for 2013/14 which are still under discussion as of the date of this report are outlined below. Develop a service specification to improve the smooth transition and have a person centred planning and flexible approach to the transition of children and adolescent service users into the adult mental health services To improve physical health outcomes for patients given the impact of physical morbidity in mental health users and the mortality among those with mental illness Patient Access - development of a Directory of Services for Choose and Book and selfreferral to the Advice Referral Centre 2.6 CARE QUALITY COMMISSION (CQC) REGISTRATION The Care Quality Commission (CQC) is the independent regulator of all health and social care services in England. Its primary role is to ensure that the care people receive meets essential standards of quality and safety and to encourage on going improvements by those who provide or commission care. CPFT 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 CPFT during 2012/13. CPFT has participated in two investigations by the Care Quality Commission relating to the areas outlined in the facing page during 2012/ CQC INSPECTIONS We had two conditions on our registration at the beginning of 2012/13 resulting from investigations carried out in the previous year: minor concern on Outcome 16 (Assessing and monitoring the quality of service provision), and moderate concern on Outcome 1 (Respecting and involving people who use services). A summary of the CQC inspections and reviews during the year and the outcomes thereof is outlined in Table 4. Improvement actions were also identified in our inpatient units on the following areas: Fulbourn Hospital site: Outcome 10 (Safety and suitability of premises) around providing better facilities that allow patients to access peaceful and private spaces or rooms Cavell Centre site: Outcome 4 (Care & welfare or people who use the services) around ensuring that care records provide clear information about any untoward event experienced by patients, and Outcome 10 (Safety and suitability of premises) around ensuring that patients have freer access to outside areas and this is managed according to their assessed risk. The inspection carried out in June 2012 in the Fulbourn Hospital site found us to be fully compliant with Outcomes 1, 4 and 14. They identified concerns in Outcome 9 (Management of medicines), particularly in relation to recording of medicines administration and the recording of medicines used on a discretionary basis (PRN) to control a person s challenging behaviour. The CQC also identified concerns against Outcome 16 (Assessing and monitoring the quality of service provision) to fully strengthen and develop its Board of Directors and to deliver a clear and effective strategy to improve, monitor and maintain the quality of its services. Page 28 of 66 Draft May2013/WLlaneza

170 The CQC carried out a table top review of evidence for Outcome 9 and 16, and an inspection in the Cavell Centre site in December The report was published in February 2013 which declared the Trust fully compliant in all areas covered by the review. Table 4: Summary of investigations carried out during 2012/13 Inspection dates As of 31 March 2012 June 2012 inspection December 2012 table top review December 2012 inspection As of 31 March 2013 CQC Outcomes Outcome 10 Fulbourn Hospital Judgement improvement actions CQC Outcomes Outcome 4 Outcome 10 Cavell Centre Judgement improvement actions improvement actions Outcome 16 minor concern Outcome 16 minor concern Outcome 1 Outcome 4 Outcome 9 minor concern Outcome 14 Outcome 16 moderate concern Outcome 9 Outcome 16 Outcome 1 Outcome 1 Outcome 7 Outcome 13 Outcome 16 Outcome 18 Outcome 20 moderate concern Outcome 1 Outcome 1 Outcome 4 Outcome 7 Outcome 9 Outcome 13 Outcome 10 Outcome 16 Outcome 14 Outcome 18 Outcome 16 Outcome 20 A number of actions were taken in 2012/13 that secured full compliance with the CQC standards by the end of the year. A summary of the key actions are outlined overleaf. Excerpts from CQC reports are also shown overleaf. Page 29 of 66 Draft May2013/WLlaneza

171 Excerpts from CQC reports July 2012 report People told us that staff treated them respectfully and in a way that they liked. One person commented, "Some staff are really good, really on the ball, quite sensitive to how you're feeling". Another person who had been a patient previously told us, "It's so nice having my own room now. I sleep better and have privacy to lie down for half an hour if I want". Another person commented, "I've recently started water tablets so having the en suite toilet is a god send". (pg 8) As part of our inspection we undertook a short SOFI (Short Observational Framework for Inspection) on Willow Ward. SOFI is a tool which provides us with information about people's experiences of their care, their general mood state and their engagement and interaction with those providing their care. Throughout our observation we noted that people showed signs of well being and were calm, relaxed and engaged in what was going on around them on the ward. The quality of interaction between people and staff was mostly very good, with staff showing respect and empathy to people. For example, we observed two staff members assist one person to move between an armchair and a dining room chair. This was done well with staff explaining to the person throughout the transfer what they were doing and also reassuring them appropriately when they became agitated during the move. We saw a member of staff talk to one person about his mother's Irish stew (which was on the menu that day), resulting in much laughter between them. On another occasion we noted that one person's unusual request for what they wanted for their lunch was fully respected by staff. We witnessed staff knocking on people's bedroom doors and waiting for a response before they entered, and people (both staff and patients) being refused entry to the ward's clinical room when treatment was being given to people. (pg 9) January 2013 report We inspected a ward for older people living with dementia. Staff on this ward were busy, but people's needs were met in a calm, professional and unhurried manner. We spoke with relatives, one of whom said, "The staff are beautiful, they're angels. They're all nice, there's not one nasty one. There are plenty of staff." Another relative told us that all the staff are " fine" but said there were times, when the ward was full and in the evenings, when " they could do with more staff." Senior staff on this ward told us they had introduced a 'twilight shift' to improve the service offered in the evening and that there were enough staff to meet people's needs. (pg 8) Our inspection of February 2012 identified that there was an inconsistent approach to the way in which people's dignity was upheld and maintained. In their declaration of compliance with this regulation, the trust told us they had done a lot of work to turn this around. They had introduced a number of measures to check that people had a positive experience during their admission to the wards. One of these measures, REV (Respect, Empower, Value), involved assessments and audits of each ward, carried out by a member of staff from another ward. During our inspection on 12 December 2012 we saw improvements on Maple 1 in the way that staff spoke with people, the way they treated people and the ways they now worked to promote people's dignity. We spent some time on the ward observing the interactions between people on the ward and the staff. Staff worked well as a team to support people. They spoke kindly and patiently to people, without being patronising, and they listened when people wanted to talk with them. The staff noted when someone was becoming agitated or behaving in a way that might upset someone else, and they responded appropriately, distracting the person and calming them. Communication on the ward had also improved. Senior staff told us that they had introduced and strengthened systems to ensure that communication between staff, people on the ward and their relatives was as good as possible. Relatives we spoke with told us that they were fully involved in the care their family member received. They felt comfortable with speaking with staff at any time, could telephone the ward for information if they were not able to visit and were confident that they would be communicated with when necessary. One relative told us they had been invited to attend the doctor's round at the end of the week. A notice board on the ward gave people information such as how to contact local support groups and advocacy services. (pg 6) Page 30 of 66 Draft May2013/WLlaneza

172 Trust actions in response to CQC findings 1. Guiding Coalition and Satellite Team The Guiding Coalition was formed in January 2012, consisting of 80 staff members from all staff groups across the Trust, to develop solutions on the areas identified for improvement and input directly into the turnaround board. A Satellite Team of around 94 staff was also formed to support the Guiding Coalition to deliver change at local level. These two groups continued into 2012/13 which made a significant impact on the success of our turnaround programme. 2. 7Cs standards of care planning The 7Cs standards were developed to assess the quality of our assessments and care planning process and documentation. Monthly peer assessments were carried out by senior clinicians involving an examination of care records and interviews with patients and staff. 7Cs was initially implemented in our inpatient units and later rolled out to community-based teams. Scores were reported as part of the quality dashboards and shared on a Trust wide basis. 3. Environmental refurbishment and repairs We started a wide ranging programme of refurbishment and repairs of all inpatient units in December 2011 following a systematic and comprehensive review of our facilities. We continued with this programme of improvement throughout 2012 and have extended the work to cover our community-based services and corporate offices coming into star environmental standards 5 star environmental standards were developed in the last quarter of 2011/12 and initially implemented in our inpatient units. This also involved monthly peer assessment carried out by senior staff and clinicians and reported as part of the quality dashboards. The 5 star assessments were piloted in our community-based teams in November 2012 March REV (Respect, Enable and Value) standards REV was developed to address the concerns around Outcome 1, and implemented in our inpatient units on a peer review basis. Teams were scored against the standards based on observations made around patient-staff interactions. Scores were reported as part of the quality dashboards. This has driven up the standards around patient-staff interactions. 6. InCA (Integrated Compliance Assessment) InCA was developed to enable teams to assess their compliance with all 16 CQC Outcomes on a monthly basis, and involved a self assessment and peer review process. It incorporates the 7Cs and 5 star standards. InCA was implemented in our inpatient units in June 2012 and piloted in selected community-based teams in March It will be rolled out to all community-based teams by the end of This provides the Trust with assurance of our compliance with the CQC Outcomes and enables us to focus our resources on areas that require action in a timely manner. 7. Medicines management action plan A set of actions were put in place to improve compliance with the standards around medicines management. Specifically, this included increasing awareness amongst nursing staff of medicines administration recording requirements and the implementation of a new when required medicines policy. Other general actions included ones identified from audit projects and the annual medicines reviews, such as the development of the Medications Competency Workbook, improving the training programme and regular monitoring of practice through the InCA process and the audit programme 8. Performance management framework Monthly triangulation meetings are undertaken with the aim of gathering all relevant information from all sources. This enabled us to use information strategically and identify possible reasons that give rise to problem areas. This information informed the Divisional Performance Review meetings. This has strengthened Divisional accountability over performance issues and ensured that appropriate actions are taken in a timely manner. Page 31 of 66 Draft May2013/WLlaneza

173 2.6.2 MENTAL HEALTH ACT INSPECTIONS Throughout the year, the CQC conducted a number of reviews in respect of Trust services provided for persons detained under the Mental Health Act (MHA). The results are outlined on the right. In addition to the 8 unannounced visits, a 2-day announced visit to the Cavell Centre in Peterborough was carried out by Commissioners accompanied by an Expert by Experience, and included representatives from Peterborough City Council and Cambridge County Council. The visit focused on monitoring the compliance with the Assessment, application for detention and admission under the MHA process. The Commissioners reported very positive feedback from patients about their experience in the wards, their involvement, care and their relationship with staff. They found the relationship between the Trust and external agencies to be effective and engaging and reported good governance and procedural arrangements. They also found the Approved Mental Health Professionals (AMHPs) assessment procedure to be effective and were satisfied with the Mental Health Act Administration, quality assurance processes, and compliance with the Act s legal requirements. Minor concerns around the unit s 136 suite environment were raised (Section 136 -Place of safety) and at the time of this report, the Trust still awaits the formal CQC recommendations, which will aide the current review of S136 functions across the Trust. MHA inspections in 2012/13 8 unannounced visits 13 units inspected 12 patients interviewed 14 sets of case notes scrutinised Good practice noted. Completion of previous recommendations Compliance with reading and reminding patients of their rights Good patient involvement in care planning Good interaction and engagement between patient and staff Access to advocacy services Recommendations for S58 Improve practice around recording of capacity to consent treatment assessments Review recording process of risk assessments carried out prior to authorising S17 leave These findings were also highlighted by our local audits. Actions have been developed to address these areas. The CQC has not published the Mental Health Act annual statement for the review period 2012/13, as of the date of this report. 2.7 DATA QUALITY AND INFORMATION GOVERNANCE CPFT submitted records during 2012/13 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 published data: which included the patient s valid NHS number was: o 99% for admitted patient care which included the patient s valid General Practitioner Registration Code o 99% for admitted patient care was 99% CPFT s Information Governance Assessment Report overall score for 2012/13 was 79% and was graded GREEN The Trust was not subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission. Page 32 of 66 Draft May2013/WLlaneza

174 CPFT will be taking the following actions to improve data quality: Rolling out RIO Electronic Care Record System across all dclinical Divisions and teams Undertaking monthly non compliance audits of 7 day follow up and CRHT gatekeeping indicators Developing an automated system for the capture and reporting of Mental Health Act compliance A data cleansing exercise for ESR and an exercise to support the standardisation of roles Developing and rolling out InCA to record and report upon compliance with the 7Cs care planning standards Developing a protocol which outlines the calculation methodology for all performance indicators on the Trust dashboard. 2.8 MANDATORY CORE SET OF QUALITY INDICATORS From 2012/13, all Trusts are required to report against a core set of quality indicators using data for the last two reporting periods provided by the Health and Social Care Information Centre (HSCIC). The indicators that are relevant to CPFT are listed below. Table 5: Mandatory core quality indicators for 2012/13 Prescribed information 1. The percentage of patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric in-patient care. 2. The percentage of admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper. 3. The 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. 4. The Trust s Patient experience of community mental health services indicator score with regard to a patient s experience of contact with a health or social care worker. 5. The number and, where available, rate of patient safety incidents reported within the Trust, and the number and percentage of such patient safety incidents that resulted in severe harm or death. Where the data reported in the HSCIC indicator portal does not reflect the most current data, we have provided current data available from the Trust. Note: For a full definition of the quality indicators 1, 2 and 5 see page 57 in Annex 2. Page 33 of 66 Draft May2013/WLlaneza

175 2.8.1 Patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric inpatient care during the reporting period. Table 6 shows that CPFT is only two points below the national average rate of 97.60%, while four Trusts achieved 100% in 2011/12. Trust performance as of March 2013 is 95.24%, hence meeting the target of 95%. CPFT considers that this data is as described for the following reason: We compared the data with our performance data submitted in the same period and both sets of data are in agreement. Table 6: Patients on CPA followed up within 7 days Reporting period 2012/13 (CPFT data) Oct-Dec 2012 (HSCIC data) Jul-Sept 2012 (HSCIC data) CPFT 95.24% 95.2% (n=334/351) 95.7% (n=337/352) England average Highest rate Not yet available from HSCIC Lowest rate 97.60% % 93.00% 97.20% % 89.80% Chart 1: Patients on CPA followed up within 7 days Target 95% (CPFT) 95% (national) CPFT intends to take/has taken the following actions to improve this 95.24%, and so the quality of its services, by: reviewing our Discharge Policy and procedures continuing to report on this indicator through our quality dashboards Admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper during the reporting period. Table 7 shows that CPFT had the lowest rate nationally for the period Oct-Dec 2012, with 18 Trusts achieving 100%. Trust figures as of March 2013 is 95.24% which meets our target of 95% and shows an improvement from 91.74% in 2011/12. CPFT considers that this data is as described for the following reason: We compared it with our performance data submitted in the same period and both sets of data are in agreement. CPFT intends to take/has taken the following actions to improve this 95.24%, and so the quality of its services, by: redesign of our clinical services monitoring performance through our quality dashboards making this our quality priority under the Clinical Effectiveness domain for 2013/14. Table 7: Admissions gatekept by CRHTT England Highest CPFT Lowest rate average rate 95.24% 90.7% (n=390/430) 91.7% (n=409/446) Not yet available from HSCIC 98.40% 100% 90.70% 98.10% 100% 84.00% Chart 2: Admissions gatekept by CRHTT Target 95% (CPFT) no national target Page 34 of 66 Draft May2013/WLlaneza

176 2.8.3 Staff employed by, or under contract to, the Trust during the reporting period who would recommend the Trust as a provider of care to their family or friends. Table 8 below shows the proportion of our staff who would recommend CPFT as a provider of care to their family and friends in 2011 and 2012, compared with the average, highest and lowest scores for all mental health Trusts and all healthcare providers in England who took part in the survey. In 2012, we scored the lowest among all mental health Trusts. Table 8: Staff who would recommend CPFT as a provider of care to their family or friends. Reporting period CPFT Average rates Highest rates Lowest rates Mental Health England (all Trusts) Mental Health England (all Trusts) Mental Health England (all Trusts) % 58% 63% 80% 94% 39% 35% % 58% 60% 83% 96% 43% 22% CPFT considers that this data is as described for the following reason: We checked it against the national report for CPFT. Chart 3: Staff who would recommend CPFT CPFT intends to take/has taken the following actions to improve this 39%, and so the quality of its services, by: talking to our staff to find out the issues they are facing and what we need to do to make it better. developing an action plan to address the issues that came out of the National NHS Staff Survey. developing a Workforce Strategy in consultation with our staff Patient experience of community mental health services indicator score with regard to a patient s experience of contact with a health or social care worker during the reporting period. The weighted average of our scores for these questions is shown in Chart 4 below, compared with the average, highest and lowest scores of all community mental healthcare providers in England who took part in the survey. This indicator uses the weighted average for the following questions in the CQC survey of community mental health services: Thinking about the last time you saw this NHS health worker or social care worker for your mental health condition Did the person listen carefully to you? Did this person take your views into account? Did you have trust and confidence in this person? Did this person treat you with respect and dignity? Chart 4: Patient experience scores Page 35 of 66 Draft May2013/WLlaneza

177 It is worth noting that our scores are higher than the national average for this indicator in both years (see section for further details on our national Community Patient Survey 2012). We believe that the heart of a quality service lies in the relationship between a member of staff and their patients. Quality comes when this relationship is based on values of trust, respect, and mutual endeavour to improve the patient s health, well being and quality of life. All members of our staff are expected to uphold and promote these principles which are embedded in our four key values outlined below: CPFT s Four Key Values Patient first: we focus on the needs of the whole person, we aim to consistently 1 exceed the expectations of our patients and their carers by making every interaction with them count Only the best: we have high standards in all that we do, we are uncompromising in our pursuit of excellence, we only do what is known to work, we evaluate everything that we do and share the data with others to allow them to hold us to account. Staff matter: we trust, value and develop each other, we build a great place to work where people are inspired to be the best they can be, where they are engaged in decisions that affect them and where they are empowered to deliver better and safer services. Together as one: we value our teams and our partners and believe we can achieve more by working together for the benefit of the people we serve. The graph below is taken from the 2012 CQC Community Patient Survey report. The black diamond in the bar represents the score for CPFT while the green bar represents the scores of the best performing Trusts in the country. We are very pleased with these results and we are very proud of our staff for the commitment and dedication that they have shown to their work and most importantly, their patients. CPFT considers that this data is as described for the following reason: We checked it against the National NHS Community Patient Survey report for CPFT. CPFT has taken the following actions to improve this 89.32%, and so the quality of its services, by: sharing these results with our staff and developing a Trust action plan to address the issues identified in the patient survey results developing a Partnership Strategy appointing a Head of Patient Experience and Engagement Page 36 of 66 Draft May2013/WLlaneza

178 2.8.5 The number, and where available, rate of patient safety incidents reported within the Trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death. The data reported in the HSCIC indicator portal, which is derived from the NRLS (National Reporting and Learning System), are presented in six month periods up to March For comparison purposes, we have only taken figures reported by mental heath providers that have submitted six months worth of data per 1000 bed days. It is worth noting that: all mental health providers calculate their rates per 1000 bed days 12 PCTs also reported 6 months worth of data which were calculated per 1000 bed days, these were excluded from the figures presented in this section. Within this group, one PCT reported an incident rate of 157, two PCTs reported 118, and one of each reported an incident rate of 95 and 77. The highest rate reported by a mental health provider is 59. Other healthcare providers (Acute Specialist, Ambulance, large Acute, medium Acute, small Acute and PCTs with inpatient provision) that report data calculated per 100 admissions were excluded from the comparative figures as our data would not have been comparable with the data reported by these healthcare providers. We have also presented data for incidents reported in the Trust during 2012/13 that are not yet reflected in the HSCIC indicator portal as of the date of this report in order to present our most up to date performance data. CPFT considers that the data presented in this section is as described for the following reasons: We checked the data presented in the HSCIC indicator portal against the data recorded in Datix, our incident reporting system. Where there were variances between the NRLS data and the data in our system, we identified the incidents that did not appear in the NRLS system to reconcile both sets of figures. Those that did not appear in the NRLS system were either non-reportable incidents considered by NRLS as not related to patient safety, incidents reported late that were outside of the reporting periods or incidents that are still under review as of the date of reporting. CPFT has taken the following actions to improve this 0.73 and 0.48 (rate of patient safety incidents that resulted in severe harm or death), and so the quality of its services, by: We have reviewed our Policy and Procedure for Reporting, Managing and Investigating Incidents Including Serious Incidents (SIs). The revised version has been approved and ratified. We have started to deliver additional Root Cause Analysis (RCA) training We have established a Serious Incident Group We have appointed a Patient Safety Lead for the Trust who will lead and work with the Clinical Divisions on the management of incidents and serious incidents in the Trust We are working with our commissioners and with our partner organisations in the development of an over arching Suicide Prevention Strategy for CPFT that links with the national and regional strategy We are monitoring all relevant data and information around incidents and serious incidents through our quality dashboards reporting framework We have commissioned Professor Louis Appleby to undertake a review of selected serious incidents in order to identify further areas for improvement We are undertaking a Trust wide Clinical Risk Assessment audit to investigate compliance with our Clinical Risk Assessment and Care Planning Policies, planned in 2013/14 Page 37 of 66 Draft May2013/WLlaneza

179 1. Number of patient safety incidents Data available from the HSCIC indicator portal during the reporting periods April September 2011 and October March 2012 are presented below. 2012/13 data is not yet available from the HSCIC indicator portal. Trust data showing figures for 2012/13 are shown in Table 9. Chart 5: Number of patient safety incidents Data reported by NRLS shows that CPFT is in the highest quartile of 57 reporting mental health providers in the country. Chart 5 shows that the number of patient safety incidents reported by CPFT is comparable to the average numbers reported by other mental health providers. 2. Rate of patient safety incidents Data available from the HSCIC indicator portal during the reporting periods April September 2011 and October March 2012 are presented below. Chart 6: Patient Safety Incidents per 1000 bed days Chart 6 shows that CPFT s rate of patient safety incidents is higher than the average for mental health providers but much lower than the highest rate reported. Refer to item 4 for additional information. Note: The Trust s reporting of all incidents, including serious incidents, has been subject of rigorous review by the CQC and as a consequence changes to our reporting processes were put in place from Patient safety has been one of our main focuses in the past couple of years. We have improved training and raised awareness of patient safety incidents. We have worked with our Divisions and clinical teams in reviewing the incident reporting process and procedures. We have processes in place to monitor, through our governance arrangements, patient safety incidents. This has resulted in a higher rate of reporting. According to NPSA Organisations that report more incidents usually have a better and more effective safety culture (NRLS patient safety incidents monthly reports for CPFT). Page 38 of 66 Draft May2013/WLlaneza

180 Charts 7 and 8 show that a higher proportion of our incidents result in no harm compared to other mental health Trusts. This indicates a good culture of reporting in CPFT. Chart 7: Apr Sep 2011(NRLS 2011) However, a slightly higher proportion of our reported incidents result in moderate harm and death which is reflected in the data reported in item 4. Data for the top 10 incident types reported by NRLS (see Chart 9 below) shows that CPFT is reporting higher rates of self-harming behaviour. This may be explained by our Complex Cases ward and Adolescent ward which are part of our Acute Care Service and who are reporting over half of the incidents in the Trust. We are reporting significantly lower rates of incidents relating to patient accidents and medication. Improving patient safety is a Trust priority. We have adopted the 7 steps to patient safety in mental health published by the National Patient Safety Agency (NPSA) to better support our staff to ensure they manage risk effectively and improve the safety of our patients. Chart 8: Oct Mar 2012 (NRLS 2012) Chart 9: Apr Sep 2011 Top 10 incident types (NRLS 2011) Page 39 of 66 Draft May2013/WLlaneza

181 3. Proportion of CPFT patient safety incidents that resulted in severe harm or death Data available from the HSCIC indicator portal during the reporting periods April September 2011 and October March 2012 are presented in Table 9 below, along with CPFT data for the period 2012/13 as follows: April September 2012 submitted and reflected in the NRLS website October 2012 March 2013 submitted to the NRLS system but not yet final Table 9: Incidents resulting in severe harm or death Reporting period Oct 12-Mar 13 (CPFT data) Apr 12-Sep 12 (NRLS data) Oct 11-Mar 12 (HSCIC data) No. of incidents reported Incidents resulting in severe harm Incidents resulting in death Total incidents resulting in severe harm or death % % % % Apr 11- Sep 11 (HSCIC data) % 4. Rate of patient safety incidents that resulted in severe harm or death Chart 10: Incidents resulting in severe harm or death Data available from the HSCIC indicator portal during the reporting periods April September 2011 and October March 2012 are shown in Chart 10 on the right. Note: Data for 2012/13 is not yet available from HSCIC. However, both sets of figures (Table 9 and Chart 10) show a 14% reduction in our incidents resulting in severe harm or death during 2012/13 (72 in 2011/12 to 62 in 2012/13). The proportion of incidents resulting in severe harm or death is also slightly lower from 2% in 2011/12 to 1.4% in 2012/13. During the year, we made significant improvements in our ward environments. This includes removing all ligature points in our wards and any fixture that patients could use to harm themselves or others. We also put measures in place to reduce the risk of absconsions which includes reinforcing doors and windows, raising the height of garden walls and moving garden benches away from the garden walls, among others. In addition we developed a policy and improved arrangements around access to our wards and improved clinical risk assessment training which showed increased levels of attendance during the year. These measures appear to have made a positive impact on our patient safety incidents during the year. Moving forward, the review currently being undertaken by Professor Louis Appleby will provide us with valuable learning in order to make improvements in this area. Page 40 of 66 Draft May2013/WLlaneza

182 PART 3: OTHER INFORMATION 3.0 OTHER CPFT QUALITY PERFORMANCE INDICATORS 2012/ PATIENT EXPERIENCE Mental Health Act Compliance Reading of Rights Reading of Rights is the first item in our quality dashboard and we have a target of 100%. As of March 2013, the total average compliance rate was 91%. The monthly trend is shown in Chart 11 on the right. Chart 11: Reading of Rights We are working with our Modern Matrons and Ward Managers to highlight the importance of this statutory requirement. This is also monitored through our InCA process Complaints and Patient Advice and Liaison (PALS) There was a 37% reduction in the Chart 12: Complaints during 2012/13 number of complaints received from 118 to 74 in 2012/13. This figure is relatively small when taken in the context of the total number of episodes of care (approximately 22,144 during 2012/13). Monthly trends are shown in Chart 12 on the right. Greater engagement between complainants and our staff, together with the revised complaints process and the implementation of effective action plans, has increased carer and patient confidence in the process. Actions taken that have contributed Chart 13: PALS contacts in 2012/13 to this improvement include: Better engagement with families Early PALS involvement Clear and timely information with patients and carers Working with Complaints Advocacy There was a very small reduction in PALS contacts from 538 in 2011/12 to 500 in 2012/13. The monthly figures are shown in Chart 13. Page 41 of 66 Draft May2013/WLlaneza

183 3.1.4 Mandatory Care Quality Commission Patient Survey The results of our CQC Community Patient Survey 2012 show an overall improvement in our scores in This is largely due to the work we have done around improving the quality of our care plans and the involvement of patients and carers in planning their care. CPFT results on the overall satisfaction rating have steadily increased over time as shown in Chart 14 below. Chart 14: CPFT scores for quality of care over time (Quality Health 2012) It is worth noting that these results are supported by findings from the National Audit of Schizophrenia 2012, whereby 81% of our patients reported a positive experience of our service against the national average of 76%, while 84% reported positive outcomes of care against a national average of 79%. Our top 5 and bottom 5 scores are shown below. This shows that our patients are happy with the quality of their relationship with our staff and their involvement in planning their care. These scores are reflected in our internal patient surveys. Table 13 below also shows that we have improved in three out of the five bottom scoring items in the survey. Table 12: Top 5 scores Questions Change Did this person (health and social care worker) treat you with respect and dignity? Did this person listen carefully to you? Did this person take your views into account? Do you have trust and confidence in this person? Were you given a chance to express your views? Table 13: Bottom 5 scores Questions Change In the last 12 months, have you received support in getting help with your care responsibilities? In the last 12 months, have you received support in getting help with finding or keeping work? Has anyone in the NHS mental health services ever asked you about your use of non-prescription drugs? In the last 12 months, have you received support in getting help with your physical health needs? Were you told about possible side effects of the medication? Page 42 of 66 Draft May2013/WLlaneza

184 3.1.3 Trust Inpatient Survey Inpatient survey data collection commenced on 26 January The inpatient survey consists of 19 questions that are taken from the national patient survey. This is shown below. At the end of March 2013, 2655 questionnaires were completed with an overall satisfaction rating of 82% (January 2012 March 2013). Trust inpatient survey questions 1 When you arrived on the ward did the staff make you feel welcome? 2. Do you feel safe during your stay? 3. Do you have trust and confidence in our staff? 4. Do you feel you are treated with respect and dignity by our staff? 5. Are you involved as much as you want to be in decisions about your care and treatment? 6. Do you know who your care coordinator or named nurse or lead professional is? 7. Do you have a care plan? 8. Do you understand what is in your care plan? 9. Have you had a care review meeting to discuss your care? 10. Are the purposes of medication and treatments explained in a way you can understand? 11. Are there enough activities available for you?? 12. Do staff listen carefully to you? 13. How would you describe the food on the ward? 14. Have you been offered a choice of food at mealtimes? 15. Have you been offered support in finding or keeping accommodation? 16. Have you been offered support in finding or keeping work? 17. Have you been offered support in seeking help with financial advice or benefit? 18. How would you rate the care you receive? 19. How likely is it that you would recommend this Trust to your friends and family Table 14: Top 5 scores Questions Q1 Q2 Q3 Q4 Overall 2012/13 When you arrived on the ward did the staff make you feel welcome? Do you have a care plan? Have you been offered a choice of food at mealtimes? Do you have trust and confidence in our staff? Do you feel you are teated with respect and dignity by our staff? Three of our top scoring areas are around the quality of the staff relationship with our patients which mirrors the results of our National Community Patient Survey. It is also worth noting that patients report highly around having a copy of their care plan. Examples of comments made by patients are shown below. I am writing to express our thanks and appreciation to CPFT. I am a mother of a 17 yrs old girl who has just been discharged from CPFT, having spent 5 years being treated for anorexia and depression, both as an outpatient and an inpatient. The care and support our daughter received was truly outstanding. We feel so fortunate to have received such support from dedicated professionals with years of specific experience in treating adolescents with eating disorders. We know from talking to parents of sufferers in other parts of the country how this level of expertise and experience is not common and yet it was vital to our daughter s progress and to the wellbeing of the wider family. The critical factor in our daughter s recovery has been the wisdom, skill and kindness of the staff in teaching both her and ourselves how to manage her condition. Page 43 of 66 Draft May2013/WLlaneza

185 Thank you for listening to me, talking and comforting me after my bad dream yesterday. I would very much like to thank all of the nurses that have been working here looking after me. (name of staff) saved my life not directly but by talking to me and making himself approachable, like all staff have. I felt comfortable to go to him and tell him the thoughts I was having I will always be grateful to the staff here for what they are doing for me and for others. Without knowing it you save lives by instilling the belief that we will get over our afflictions. I think when I am fully recovered and out of the army I will try to help those in a similar position because I see that it is a very important job that does not seem to get much recognition Comments received from patient surveys The service from the team and the Trust has been fantastic and I cannot thank them enough for my care and treatment in helping me get through a very difficult time. The facilities and activities available are far more that I would have expected and I feel this is just as important or even more important in certain situations than the use of only drugs. The care staff have gone above and beyond anything that I could have expected, they are a very special kind of people. I ve been involved in my treatment more than I expected. I ve been allowed to voice my opinion without feeling afraid or scared. I ve been listened to and given very important advice for during and after treatment. Every decision has been made clear and I am thankful for that. Good food and friendly staff. High standards of food received whilst on the ward. Flexibility of visits by my family members. Table 15: Bottom 5 scores Questions Q1 Q2 Q3 Q4 Overall 2012/13 How likely is it that you would recommend this Trust to your friends and family? How would you describe the food on your ward? Have you been offered support in finding or keeping work? Have you been offered support in seeking help with financial advice or benefits? How would you rate the care you receive? Table 15 above shows the specific areas that we need to focus on. It is worth noting that while our patients are happy with the choice of food, we need to work on improving the standard of the food on our wards. We have established a Food Focus Group to drive up the standards and quality of the food on our wards. We are also working with our provider around improving the presentation of the food as well as the environments in which these are being served. We are also working on embedding recovery principles in our practice and services. The Recovery College East which was opened in November 2012 will enable people who use or have used secondary services from CPFT to develop new skills or increase their understanding of the mental health challenges that they have. Our Peer Support Worker programme also provides valuable support to our patients. Our lowest scoring item in this survey is the Friends and Family test with an overall average score of 20%. This was our quality priority in 2012/13 and we are carrying this forward as our quality priority for 2013/14. Page 44 of 66 Draft May2013/WLlaneza

186 3.1.4 Trust Community Survey Community survey data collection commenced in April A phased roll out across all community teams was completed by the end of November. The survey consists of 14 questions which are shown below questionnaires were completed by the end of March The overall satisfaction rating was 90%. Trust community survey questions 1 Are staff polite and approachable? 2. Do you have trust and confidence in our staff? 3. Do you feel you are treated with respect and dignity by our staff? 4. Do staff listen carefully to you? 5. Are you involved as much as you want to be in decisions about your care and treatment? 6. Do you know who your care coordinator/therapist/key worker or lead professional is? 7. Do you have a plan of care/treatment/ therapy? 8. Do you understand what is in your plan of care/treatment/therapy? 9. Have you had a care review meeting to discuss your care/treatment/therapy? 10. Could you bring a friend, relative or advocate to your care review meeting? 11. Are the purposes of medication and treatments explained in a way you can understand? 12. Do you have the telephone number of someone from the Trust that you can phone out of office hours? 13. How would you rate the care/treatment/therapy/ activities you receive? 14. How likely is it that you would recommend this Trust to your friends and family? Table 16: Top 5 scores Questions Q1 Q2 Q3 Q4 Overall 2012/13 Are staff polite and approachable? Do you feel you are treated with respect and dignity by our team? Do you have trust and confidence in our staff? Do staff listen carefully to you? Are you involved as much as you want to be in discussions about your care? Examples of comments received from our community patients are shown below. Table 17: Bottom 5 scores Questions Q1 Q2 Q3 Q4 How likely is it that you would recommend this Trust to your friends and family? Do you have the telephone number of someone from the Trust that you can phone out of office hours? How would you rate the care/treatment/therapy/activities you receive? Have you had a care review meeting to discuss your care/treatment/therapy? Could you bring a friend, relative or advocate to your care review meeting? Overall 2012/ Four out of the five top scoring items refer to staff attitude and the quality of their relationship with our patients, while the fifth one pertains to the quality of the patient s involvement in planning their care, treatment and support. These results mirror our national and inpatient survey results and reflects the work that we have done around the 7Cs care planning standards and the improvement in collaborative practice with patients in the care planning process (see section 4.3.1). Our bottom five scores also appear to mirror the results of our inpatient survey results. It is worth noting however that the scores for the Friends and Family test are higher than the Trust target of 30% (see quality priority 1 in section 1.2.1). We have adjusted our target for 2013/14. Page 45 of 66 Draft May2013/WLlaneza

187 The introduction of the ARC (Advice and Referral Centre) will address the issue around out of hours contact. Likewise, we expect that the restructuring of our community services and development of Care Pathway teams will have a positive impact on the quality of care provided. Comments received from patient surveys There is always someone at the other end of the phone if we need them. All our questions, no matter how silly we think they are, are always answered in a way that we understand. We are treated with respect. Thers is always somebody available to do a home visit when needed. Good rapport with support worker. Helpful and friendly advice. They have taken the time to understand who I am and help me understand my condition. Very helpful, friendly and understanding. Any concerns and necessary changes have been dealt with immediately. I am treated like a human being. The consistency and professionalism of the service has made me feel valued and accepted and encouraged me to live as fulfilling a life as possible given the limitations of my long term mental health issues. Always given advice on what is more favourable but given the choice of deciding what I personally feel will eb better. Very friendly and find it easy to talk to. 3.2 PATIENT SAFETY Our performance in 2012/13 on patient safety quality indicators (i.e., suicide prevention, physical assaults and absconsions, patient safety incidents and mandatory training including safeguarding children and adults training) have been discussed in previous sections of this Quality Report. Additional quality indicators are outlined below Reducing Healthcare Associated Infections (HCAIs) The Trust remains committed to ensuring patients receive care in clean and safe environments. During the year we continued to build on the measures put in place in order to support good practice and reduce the risk of infection. The e-learning training programme which runs alongside the face-to-face training helps to ensure that staff maintain their knowledge and skills in the control and prevention of infection. We have made significant improvements in training as compared to the previous year as shown in Chart 15.. Chart 15: Infection Prevention & Control Training HCAI incidents in 2012/13 1 incident of C Difficile in 2012/13 which is the same as the previous year. This was investigated fully through our SI process 3 closures of wards due to diarrhoea and/or vomiting. The protocol was followed thereby ensuring the safest care for our patients and staff One ward had two separate episodes of scabies. Page 46 of 66 Draft May2013/WLlaneza

188 3.2.2 MRSA Screening All patients admitted into our wards are screened for MRSA, and those who fit into higher risk categories are offered swabs. We have made huge improvements in 2012/13 and compliance level is much improved as shown in Chart 16 below. Actions we have taken/are taking to ensure consistent achievement of the target include: continued provision of Infection control training identification of Infection Control leads/link workers in each service monthly reminders to ward managers, link workers and modern matrons monitoring of performance through our quality dashboard Chart 16: MRSA screening Pressure Ulcers Chart 17 shows the number of PUs reported during the year. Of the four reported that were attributable to the Trust, two were grade 2, one was grade 3 and another one was a grade 4 PU. The increase in grade 2 cases reported is most likely due to improved level of awareness regarding pressure ulcers and care of the skin. Other examples of good practice Chart 17: Incidence of Pressure Ulcers reported via Datix that are in place are listed below. Modern Matron for Infection Prevention & Control identified as dedicated Trust lead for PUs. Use of NICE Guidance (CG29, 2005) and the European Pressure Ulcer Advisory Panel (EPUAP) guidance Information resources available on PU page on the Trust intranet for staff Use of the Waterlow assessment tool as part of the physical examination on admission Reporting and investigation of all PUs through Datix, our incident reporting system. In accordance with national guidance, any pressure ulcers of grades 3 or 4 are treated as a Serious Incident. All actions resulting from investigations have been completed NHSLA The NHS Litigation Authority handles negligence claims and works to improve risk management practices in the NHS. The Trust achieved Level 2 accreditation in February The Level 3 assessment was originally scheduled in February This has been moved to February 2015 by NHSLA following a review of their standards and assessment process. An action plan is in place to help us prepare for the Level 3 assessment. Page 47 of 66 Draft May2013/WLlaneza

189 3.3 CLINICAL EFFECTIVENESS Care Planning Care planning is an on-going quality priority of the Trust. In 2010/11, our priority was to ensure that 95% of our patients have a care plan and we consistently met this target over the last three years (see 1.3). In 2012/13, we shifted our focus on improving the quality of our care plans (see 1.2.1). We developed the 7Cs standards to clearly define the standards expected of our care plans and implemented a process of monthly self and peer assessments. The scores are reported through our quality dashboards and performance management framework. Our work on improving the quality of our care plans contributed towards achieving compliance with the CQC standards and improvement in our 2012 national patient survey scores, with the section on care plans showing the largest improvement. The graph below shows we scored higher than the national average around patients understanding their care plan. This was acknowledged by our CQC assessors who praised the improvements we have made in the quality of our care plans during the year. The 7Cs standards are grouped under the following main headings: Comprehensive and crosschecked Collaborative Clear and concise Choices Crisis/contingency Carried out Carers and care for The standards are used to assess the quality of the care plans and include a section for patients and/or their carers where appropriate to give feedback on their views about their care plan and their involvement in planning and reviewing their care. CQC, National Community Patient Survey 2012 Page 48 of 66 Draft May2013/WLlaneza