annual report and accounts 2015/16...but one (a&e four-hour target) of monitor’s performance...

Annual Report and Accounts2015/16

The Hillingdon Hospitals NHS Foundation Trust

The Hillingdon Hospitals NHS Foundation TrustAnnual Report and Accounts 2015/16

Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the

National Health Service Act 2006.

5Annual Report and Accounts 2015/16

1

cont

ents

1. Performance Report

2. Accountability Report

2.1 Directors’ Report

2.2 Remuneration Report

2.3 Staff Report

2.4 Compliance with NHS Foundation Trust Code of Governance

2.5 Regularity Ratings

2.6 Statement of Chief Executive’s Responsibility as Accounting Officer

2.7 Annual Governance Statement

3. Quality Report

4. Statement of Directors’ Responsibility in Respect of the Accounts

5. Independent Auditors Report

6. Annual Accounts

6 The Hillingdon Hospitals NHS Foundation Trust

1Performance reportIt’s been both an exciting and challenging year for the Trust. We’ve seen demand for some of our services reach an all-time high and we’ve also seen a number of new developments and improvements come to fruition.


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Despite the challenges, our Trust has had a great many notable developments in the last 12 months. In 2015/16 around £3 million was invested in the expansion of our Maternity and Children’s Services. This was to accommodate the increase in demand following the closure of the Maternity Unit at Ealing Hospital, which was planned for under the Shaping a Healthier Future programme. Our maternity improvements included: the introduction of a new midwifery-led service for low risk women, the opening of new en-suite birthing rooms, and the establishment of a new transitional care service for babies that need a bit of additional support before going home. Staffing numbers have been increased to support the expansion.

We’ve also undertaken an extensive programme of development in Paediatric Services; our Children’s A&E is entering the final stages of a major upgrade that will see it completely rebuilt to high-spec, modern-day standards, featuring bigger bed spaces and a new step-down resuscitation bay. We are also at an advanced stage of building a new extension to our Peter Pan children’s ward which will provide an additional four beds, again built to modern standards. This will be complete by the end of this summer.

In addition, six of our seven operating theatres at Hillingdon underwent an extensive programme of refurbishment during last year. They now have new flooring, improved ventilation, lighting and storage. The Trust continued with its scheduled procedures throughout

Introduction from the Chair and Chief ExecutiveA marked increase in demand for services was experienced across the whole of the NHS over the last year. As with most Trusts, the surge in demand was most keenly felt in the A&E department – where our staff coped admirably despite having to manage unprecedented patient numbers.

The ongoing junior doctors’ dispute…

also had an impact on the number of operations and procedures we were able to undertake

during the course of the year. However, disruption to patients was kept to an absolute mini-

mum thanks to careful forward planning and the support of all our staff but particularly

our consultants, other clinical staff and our junior doctors who worked additional hours.

the re-fit by making greater use of its four theatres at Mount Vernon.

Towards the end of the financial year we were privileged to play host to HRH The Princess Royal who paid a visit to formally open our newly expanded Nuclear Medicine department. The department now boasts a brand new £1 million SPECT CT scanner. One of only two of its kind in the country, the new scanner enables both nuclear and MRI scans to be carried out simultaneously. This not only reduces the number of patient appointments required, but minimises stress for patients by speeding-up the process of diagnoses and the start of any course of treatment.

Elsewhere, we continue to work hard to improve our patient services. The


and actions for both patients and staff. In 2015/16 the Trust also joined Inclusive Employers (IE) which provides access to advice and support on EDI issues. Working in collaboration with IE, the Trust will be piloting its work experience programme for people with learning disabilities in autumn 2016. The Trust held a number of EDI listening exercises which attracted strong engagement from staff. This resulted in a number of key initiatives including establishment of the EDI strategic group and the development of an EDI training course to support

In 2015/16 the Trust continued investing in its clinical leadership; this investment is to ensure that the highest quality clinical services are provided to our patients. This included the launch of a brand new £240k state-of-the-art simulation centre at Hillingdon Hospital. The centre is kitted out with the most up-to-date robotic ‘patients’ currently available. It provides an excellent training facility for staff, enabling them to enhance and develop their hands-on clinical skills in a safe and supportive environment. Our clinical leaders, both medical and nursing staff, receive individual and team coaching and mentoring; also focused succession planning identifies our future clinical leaders who are then supported to achieve excellence. The Trust hopes that this investment will help us retain and develop our clinical staff.

In 2015/16, the Trust established the Equality, Diversity and Inclusion (EDI) group chaired by a Non-Executive to champion EDI issues. The group provides oversight of key EDI priorities

adoption of our Ambulatory Care model in the Acute Medical Unit (AMU) means many more patients are now able to get the care they need without being admitted to hospital. This is welcomed by those who are able to stay at home while accessing the clinics, tests and treatment they need, and good for the Trust as it means that we are more able to provide hospital beds for those that need them most.

Our highly-regarded rehabilitation service continues to go from strength to strength with Daniels Ward at Mount Vernon – which opened last year – now operating at full capacity. The Trust was also successful in securing a partnership contract with Imperial College Healthcare Trust and Central London Community Healthcare NHS Trust to provide specialist neuro-rehabilitation beds at Charing Cross Hospital. This is an important step for the Trust and makes us one of the largest providers of specialist rehabilitation in London.

Our highly-regarded rehabilitation

service continues to go from strength

to strength with Daniels Ward at

Mount Vernon – which opened last

year – now operating

at full capacity.


1We received more than 25,000 responses to the Friends and Family test (FFT) during the year with 93% of patients saying they were happy to recommend our services to their friends and family.

And we once again scored well in the national staff survey, with above average results in 18 out of 32 areas and 10 of those were ranked in the top 20% of all acute Trusts in England.

While many improvements were made to our buildings over the year, much of our estate is old and remains in poor condition. We have been frank in stating that it will require substantial investment in the near future and we will continue to work with the Department of Health, NHS Improvement, local GP commissioners and our MPs to secure the funding needed. To support the Trust’s long term aim for its estate and the health needs of the local community, we have begun the process of developing a master plan for both of our hospital sites. We will be talking to local people about these proposals in the coming year.

This year has also seen us further strengthen our partnership working. At the beginning of the year we embarked on an ambitious project with other Hillingdon care providers to deliver an integrated care model for patients over 65 years old. Significant progress has been made and plans are in place to expand the programme in the year ahead. A major milestone that all the main care providers are working

recruitment, selection and talent management within the organisation. We strive to provide the best possible care at all times and our CARES (Communication, Attitude, Responsibility, Equity, Safety) Values remain at the heart of our approach to patient care. This year saw us maintain high standards of care as demonstrated by our good patient outcomes, key quality performance indicators and the positive feedback we get from patients. The Trust was rated green (compliant) throughout the year in all but one (A&E four-hour target) of Monitor’s key performance targets. We maintained our high performance for Referral to Treatment waiting time standards and we performed better than the London and national average for the key cancer performance indicators waiting time standards. We have also seen an improvement in our mortality rates with a reduction in the variability between weekdays and weekends.

Shane DeGarisChief ExecutiveThe Hillingdon Hospitals NHS Foundation Trust

Richard Sumray ChairThe Hillingdon Hospitals NHS Foundation Trust

towards is the formal establishment of an Accountable Care Partnership (ACP) to support this work.

Another critical piece of partnership work will be the final sign-off of Hillingdon’s Sustainability and Transformation Plan (STP) which will support our collective delivery of better health care services for local people in the years ahead.

There will inevitably be new challenges ahead but we are confident that the Trust has built a solid foundation from which to face them.

We are grateful to our staff, governors, volunteers, and fellow Board members for their hard work and commitment to the Trust and the people who depend on us.

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Improving women’s and children’s services The Trust secured more than £3 million to improve and expand our children’s services as part of the Shaping a Healthier Future programme. Improvements include a new children’s A&E; four new beds on Peter Pan Ward; establishing a midwifery-led service with new en-suite birthing rooms and a new transitional care service for babies that need a bit more support before going home.

Securing new contracts The Trust successfully secured an £11 million contract, in partnership with Imperial College Healthcare and Central London Community Healthcare, to provide specialist neuro-rehabilitation at Charing Cross Hospital.

New scanning service More than £1 million was invested in establishing a new Nuclear Medical Facility housing the latest SPECT CT scanner. This enables nuclear and CT scans to be carried out at the same time reducing the need for multiple patient scans.

Performing well The Trust rated green (compliant) throughout the year in all but one (A&E four-hour target) of Monitor’s performance targets. Key cancer indicators are well maintained for all the national waiting times standards, and performing better than the London and national average. We have also seen a reduction in variation between weekend/weekday mortality;

Friends and Family Test We received more than 25,000 responses to the FFT – 93% of patients would recommend our services to their friends and family – higher than the England and London score.

Annual NHS Staff Survey 2015 Annual NHS Staff Survey – 65% of our staff said they ‘would recommend the Trust as a place to work‘- 4% higher than the average for acute Trusts. Overall, we scored above average in 18 areas with 10 of these being in the top 20% of all acute Trusts in England.

Innovation in health care support This year the Trust launched the Hillingdon Care Record (HCR). The first of its kind in the country, HCR is a digital in-house system that provides clinicians with electronic access to patient records at the bedside.

Investing in staff training The Trust created a £240k state-of-the-art simulation suite, featuring high-spec robotic model patients, ensuring staff can develop and improve their skills in a safe and supportive environment.

Refurbished facilities An extensive programme of refurbishment was carried out on our operating theatres at Hillingdon and significant upgrades were made to our pathology lab and restaurants at both sites.

Improving PLACE (Patient Led Assessment of the Care Environment) scores The Trust developed a new Cleaning Strategy supporting the drive to maintain the highest standards of cleanliness. We also improved our cleaning and patient food scores in the 2015 PLACE assessment.

Key achievements 2015-16

In2015/16:

Trust History and Purpose

The Hillingdon Hospitals NHS Foundation Trust was established on 1st April 2011 when Monitor authorised the organisation as an NHS Foundation Trust.

The Trust provides health services at two hospitals in North West London: Hillingdon and Mount Vernon. Hillingdon Hospital is the only acute hospital in the London Borough of Hillingdon and offers a wide range of services including accident and emergency, inpatient care, day surgery, outpatient clinics and maternity services.

The Trust’s services at Mount Vernon Hospital include routine day surgery at a modern treatment centre, a minor injuries unit, and outpatient clinics. The Trust also acts as a landlord to a number of other organisations that provide health services at Mount Vernon, including East & North Hertfordshire NHS Trust’s Cancer Centre.

The Trust’s income in 2015/16 was over £238 million and we employed over 3,000 staff. The majority of our patients live in the London Borough of Hillingdon but as part of our strategy we are seeking to provide healthcare to a wider area.



85,630attendances were made to our Accident & Emergency department and Minor Injuries Unit

25,256admissions were made for planned operations and day surgery

4,725babies were born in our Maternity Unit.

336,011attendances were made as outpatients.

25,440admissions were made for emergency treatment across all parts of the Trust.

In2015/16:

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We have established four strategic priorities for the future to help deliver our strategic intent and these remain unchanged since last year’s report:

(SaHF) reconfiguration of healthcare services in North West London. We also need to broaden our service offering, acknowledging that healthcare is unsustainable based on the current model of care. We will increasingly see services delivered in community settings, with a much stronger focus on early intervention, either as the prime provider or as part of a network solution.

Our objective is to be the main provider of health services in Hillingdon, but also to grow our presence and service offering in neighbouring boroughs.

The medium term strategy (next 1-3 years) is to continue to deliver safe, high quality services and be a top quartile performer for small-medium

Overview of the Trust’s strategy

The Trust’s Strategy and Business Model

The Trust’s Vision and Mission statements were re-formulated in 2013 as follows:

Vision: To put compassionate care, safety and quality at the heart of everything we do.

Mission: To be the preferred, integrated provider of healthcare for Hillingdon and the surrounding population, with a major acute hospital as a hub.

Strategic intentOur medium term strategy (3-5 years) remains focused on the development of an organisation of sufficient scale to continue to provide responsive, high quality clinical care in the most appropriate setting for patients. Our ambition is to continue to be seen as both a major acute hospital provider and an important part of a more integrated health and social care system. A key part of our longer term strategy is to obtain capital finance support to upgrade the estates infrastructure on the Hillingdon site, in the context of the Shaping a Healthier Future


1. To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide

2. To deliver a clinically led service strategy that responds to the needs of patients and other health and social care partners

3. To deliver high quality care in the most efficient way

4. To develop sufficient sustainable scale to enable us to improve and grow healthcare services for our communities.

These priorities are underpinned by more detailed strategic objectives and actions, which are refreshed each year, to ensure we deliver our strategic plan. Further information is available in the Trust’s strategic and annual plans (available on Trust website).

size acute Foundation Trusts across quality, operational and finance performance indicators. In order to achieve this, we will make sure we increase quality and safety and drive down cost wherever possible. Most immediately we are working to address the quality concerns raised by the Care Quality Commission (CQC) in its report of February 2015. We will also support the transition to a more integrated and affordable healthcare system through much closer collaboration with Hillingdon Clinical Commissioning Group (HCCG) – the main commissioner of our services – and through the development of strategic partnership arrangements with other providers.


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delivering service levels above the agreed contract. Monthly formal contract meetings with Hillingdon CCG as lead commissioner are in place so financial and service issues can be flagged and addressed as quickly as possible. Recruitment to fill vacancy levels is insufficient to enable the Trust to significantly reduce its agency costs.

This is being addressed by a focused recruitment and retention programme including overseas initiatives and is subject to continual management review.

The level of savings required in 2016/17 has an adverse impact on the quality of care provided.

To give the Trust the very best opportunity of delivering its savings, a Project Management Office (PMO) is in place to support managers and clinicians to achieve identified savings plans. Throughout the year weekly/fortnightly risk assessment allows early signs of potential areas of non-delivery to be identified and ensure mitigating actions are put in place to prevent slippage or non-delivery.

2016/17 (see section 4.4 of the Annual Governance Statement). There will be increased scrutiny of operational performance and quality data and a new accountability framework to ensure compliance with policy and delivery of statutory targets. Particular attention will be devoted to areas of outstanding compliance notices, most notable of which is infection control.

Financial risks:

Commissioning risk that Hillingdon CCG’s out of hospital strategy results in Trust deficit.

This will be mitigated by continuing to agree contracts with Hillingdon CCG that promote robust collaborative working and financial risk sharing to redesign clinical pathways, yet at the same time provide sufficient revenue to cover the Trust’s costs; including guaranteed minimum financial values that can be enhanced and/or fixed cost transitional support.

Commissioning risk if the cost of activity is not paid for in full.

The form of healthcare contract the Trust will agree with Hillingdon CCG will guarantee a minimum payment with an agreed rate for over performance. However, as was the case in 2015/16 the minimum value can be enhanced by negotiation to cover justifiable excess costs of

The Trust may fail to achieve the 95% A&E target which could lead to a breach of its Licence.

The Trust is working with Hillingdon Clinical Commissioning Group, Hillingdon Borough Council, Hillingdon Community Health and the third sector (voluntary sector) to integrate care and ensure that admissions to hospital are avoided where possible; and, that time spent in the A&E department is reduced. Action will be taken, following a recent independent review of patient flows, to and through the A&E department and into the Acute Medical Unit, to improve patients’ waits in A&E

Failure to deliver high quality patient care as a result of inadequate staffing provision and specifically inadequate staffing provision to meet the 7-day workforce initiative.

The Trust is reviewing its clinical and support service workforce using acuity and dependency tools and other mechanisms; to improve frontline clinical staff numbers and care at the bedside seven days a week. The Trust will continue to drive forward a robust recruitment and retention work programme to reduce the number of vacancies and to support the increased activity that the Trust has seen during this past year.

Failure to comply with the expected standards set out by our regulators which could impact on the Trust achieving a ‘good’ rating with the CQC.

The Trust continues to strengthen its governance arrangements and its compliance with the Health and Social Care Act regulations through a programme of internal peer reviews and mock inspections to ensure there is evidence of improvement against a refreshed CQC action plan for

The Trust will continue to drive forward a robust recruitment and retention work programme


A monthly integrated quality and performance report is presented to the Board which covers five key domains.

1 Safe, which includes infection control, falls, maternity indicators,

safety thermometer, Serious Incidents (SIs)/never events, all patient safety and mortality standards

2 Effective, this covers readmissions and DNAs as well as

monitoring performance on the use of Choose and Book.

3 Caring, this domain monitors outputs and delivery of Friends and

Family surveys, and complaints and feedback from the Trust’s PALS.

4 Responsive, focuses predominately on the access targets reporting

on A&E, Cancer and RTT

5 Well Led, monitors recruitment and retention as well as sickness rates

and Performance Development Review (PDR) performance.

provides the majority of heat to the Hillingdon acute site has a remaining operational life of only 2-3 years.

Overall, the Trust will remain focused on the tension between quality, safety, financial efficiency, and risk to ensure that patient care remains uncompromised.

The Trust will do this by having regular Board and Executive reviews of progress and delivery of agreed plans and check that all schemes are quality impact assessed.

Going Concern1

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.

Operational Performance analysis

Approach to measuring performanceThe Trust has developed an intergraded pyramid structure of meetings supported by a number of dashboards to allow it to track all quality and performance standards. Detailed department/speciality level performance is tracked through a number of weekly and monthly meetings. These include monthly divisional reviews and Trust wide performance management meetings, in addition to weekly review by the Chief Operating Officer/Director of Operations with the Assistant Directors of Operations.

These meetings report by exception through to various committees of the Board, where further scrutiny is applied to action plans designed to improve quality and performance.

Increasing cost of compliance to meet statutory and regulatory service and infrastructure standards particularly in light of the recent CQC report.

This risk is being addressed by management with a phased approach to both revenue and capital investment over the next two financial years. The Medical Director, Nurse Director and Chief Operating Officer have together reviewed the required investment and prioritised expenditure to rectify and sustain warning notice and must-do compliance issues.

Cash required for day to day operations and for investment could fall short of what is required and start to impede on service delivery.

To manage this risk in addition to the £4.1 million cash balance at the start of the 2015/16 year and £6.0 million of assessed working capital headroom available, management has the ability to access £6m of working capital facility. In addition, a routine monthly payment has been agreed with East and North Hertfordshire Hospitals NHS Trust for services received on the Mount Vernon site thereby increasing monthly cash flow.

The estate has suffered from under-investment over an extended period and many building services have failed or are beyond their economic and design life cycle.

There is a risk that the Trust is unable to access sufficient funding to sustain safe services in the short to long term. Key facilities such as theatres, Critical Care and many wards are of a design and condition that does not lend itself to the delivery of modern high quality healthcare. A waste incinerator that

1. The Trust’s approach to Going Concern is described in Note 1 to the Financial Statements.


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Indicator Performance in 2013/14

PerformanceIn 2014/15

Performance in 2015/2016

TargetAchieved

Clostridium difficile (total) 12 18 12 n/a

Clostridium difficile (lapses of care) n/a n/a 1

All cancers: 31 days for second or subsequent treatment (surgery)

100% 100.0% 100%

All cancers: 31 days for second or subsequent treatment (anti-cancer drug treatments)

100% 100.0% 100%

All cancers: 62 days for first treatment from urgent GP referral for suspected cancer

90.3% 92.2% 91.8%

All cancers: 62 days for first treatment from NHS Cancer Screening Service referral

97.8% 97.8% 98.6%

All cancers: 31 days from diagnosis to first treatment

99.3% 99.3% 99.2%

Cancer: two week wait from referral to date first seen for all urgent referrals (cancer suspected)

97.9% 98.0% 97.0%

Cancer: two week wait from referral to date first seen for symptomatic breast patients (cancer not initially suspected)

94.7% 95.7% 96.3%

Maximum time of 18 weeks from point of referral to treatment – admitted patients

97.1% 95.2% n/a

Maximum time of 18 weeks from point of referral to treatment – non admitted patients

98.6% 98.4% n/a

Maximum time of 18 weeks from point of referral to treatment – patients on an incomplete pathway

92% 97.4% 96.1%

A&E: Total time in A&E less than 4 hours (Accident & Emergency, Minor Injuries Unit, Urgent Care Centre)

95% 94.1% 92.0%

Self-certification against compliance with requirements regards access to healthcare for people with a learning disability

Fully Compliant Fully Compliant Fully Compliant

n/a – is not applicable as data collection has changed

Overview of Performance Key Targets

The Trust maintained strong performance against all key performance targets with the exception of the A&E 4 hour standard. A 12% growth in demand over two years has now compromised the physical capacity of the department and achieving the 4 hour standard has become increasingly difficult.

There were 12 reported incidents of Clostridium difficile; however following robust root-cause analysis by the CCG and Trust it was established that there was only one lapse in care.


1The Trust continued to perform well against this standard and ended the year with a performance of 96.1%.

A&E 4 Hour StandardThe Trust did not meet the 4 hour A&E standard during 2015/16. Continuous growth in demand up by over 12% in two years has now compromised the

Cancer Performance The Trust successfully achieved all of the cancer access targets for the fourth successive year. The introduction of new systems to provide greater oversight of the patient’s pathway by all members of the multi-disciplinary team has continued to drive strong performance against these targets.

Referral to Treatment During 2015/16 compliance against the admitted and non-admitted waiting time standards were replaced by performance on incomplete pathways.

Clostridium difficile As illustrated by the following graph the Trust has made good progress in reducing the incident of reported Clostridium difficile Infection (CDI) over the past eight years. The figures for 2015/16 include the cases where the CCG have undertaken a root-cause analysis and determined that the Trust acted in the patient’s best interest. There was one case in 2015/16 where there was deemed to be lapse in care in relation to a prescription for antibiotics which was not in line with Trust antimicrobial prescribing guidelines.

Clostridium difficile Toxin Positive

Source: PHE

0

100

150

50

200

2013/14 2014/15 2015/162012/132011/122010/112009/102008/092007/08

167 156

75

24 25 2312 1218

A&E Attendances – Type 1

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1000

2000

3000

4000

5000

6000

2014-152015-16

MarFebJanDecNovOctSepAugJulJunMayApr


medical role to work between A&E and Ambulatory Care.

Additional investments were made in Ambulatory Care and there was a corresponding increase in the number of patients seen in the clinic as illustrated by the graph on the next page.

The Trust has also been working closely with Hillingdon CCG and together commissioned Method Analytics to undertake a review of flows and

approximately 14% growth in demand.

A&E Response Additional funds were made available to A&E throughout the year and extra staff were employed both in the department and in supporting services. The Trust invested in improving consultant and senior managerial cover on site over the weekend. Winter escalation capacity was opened early and investments made into a new

physical capacity of the department. During 2015/16 type 1 attendance increased by 4.9% with activity peaking in the final quarter increasing by 12% over the same period last year; as illustrated by the graph above.

Another significant contributing factor affecting the A&E performance was the consistent increase in the number of blue light (category 1) ambulances attending the Trust. During 2015/16 the number of blue light ambulances arriving at A&E increased by 24.6%. Attendances over the past two years is up by 53%.

Paediatric activity has increased by 6.2% across the year, again Q4 was particularly challenging with

A&E Attendances – Blue Light

0

50

100

150

200

250

300

2014-152015-16


A&E Attendances – Time in Resus

0

20000

40000

60000

80000

100000

120000

2014-152015-16


The increase in blue light arrivals put considerable pressure on the Trusts Resuscitation Unit consequently activity increased by 17.4% during 2015/16. The department’s physical capacity was compromised most days as demand increased by an average of 30% during quarter 4, when compared to the previous year.


financial year was a breakeven position, which was not achieved. This does however represent an improvement on the prior year when a deficit of £6.1m was recorded.

The on-going increase in demand for the Trust’s services led to a £10m increase in its income in 2015/16 when compared with the previous year. This included the transfer of some maternity activity from Ealing, though this was partly offset by the closure of step down beds previously used by patients from Northwick Park Hospital. Pay costs increased by more than the growth in activity reflecting the Trust’s efforts in recruiting to vacancies. In contrast, non-pay costs increased at a slower rate than the growth in

to be more demanding than had originally been anticipated. The impact of the changes made to services following the CQC report published in February 2015 increased costs by more than had been planned. In addition, the Trust did not achieve all the savings that it needed to deliver a breakeven position.

Despite the financial pressures on the Trust it nevertheless still managed to deliver a £10.4m programme for much-needed capital investment. Trading for the year

The Trust ended the 2015/16 financial year with a financial deficit of £1.5m. The initial planned result for 2015/16

processes in A&E. Recommendations from this review have been incorporated into a comprehensive A&E recovery action plan.

Access to healthcare for people with learning disabilitiesThe Trust continues to fully comply with the requirements regarding access to healthcare for people with a learning disability.

Financial performance analysis

Overall performance

It was known that 2015/16 would be a particularly financially challenging year for the Trust; however, it proved

A&E Attendances – Paediatrics (excl UCC)

0

500

1000

1500

2000

2500

2014-152015-16


AEC Activity 2015-16 (M1-11) – Total

0

200

400

600

1110987654321


commissioner requested services will continue to have to manage with a national tariff that will embed an efficiency saving requirement of 2% merely to standstill.

In addition to the national efficiency requirement, the Trust faces a number of other cost pressures in 2016/17, not least the requirement to invest in service quality and deliver compliance with CQC standards. The target savings from the Quality, Innovation, and Productivity and Prevention (QIPP) plan are £9.0m. The QIPP plan is supported by national work streams on capping rates paid to agencies and the work of Lord Carter of Coles to improve operational productivity. There is also coordinated work across North West London to maximise savings across a wider footprint where this is practicable.

Over the medium term, the Trust will achieve financial balance as the acute services reconfiguration in North West London is completed. Achieving financial balance, however, will require

reconfiguration of Paediatric services in Ealing during 2016/17 to increase the capacity and significantly improve the environment for inpatient and emergency services. During 2015/16 £1.4m has been invested in these areas, with a further £2.6m planned for 2016/17.

Apart from the physical infrastructure, the Trust also continued to invest in updating its medical equipment impacting on a wide range of clinical services and on information technology infrastructure and capability. Of most significance was procurement of a SPECT/CT scanner and an on-going major project to develop a Hillingdon Care Record.

Looking ahead

Given the overall 2015/16 deficit position of the NHS in England and acute providers in particular, 2015/16 was always going to be extremely financially challenging. Despite the £1.8bn of additional resource announced in the 2015 Autumn Statement all providers of NHS

revenue, reflecting the impact of the Trust’s savings programme.

The Trust achieved £8m of savings in 2015/16 (3.4% of total annual operating income), this being an increase of £0.5m on 2014/15. However, this fell short of the £9.5m target the Trust had set, thus contributing to the worsening financial position.

Cash flow

The Trust generated £17.3m of cash during the financial year, predominantly from direct healthcare related activities. Of this £5.4m was utilised to service outstanding debt and interest commitments from loans and leases, and to pay £4.2m Public Dividend Capital to the Department of Health. The £9.1m cash remaining was used to finance the Trust’s capital investment programme. The year-end retained cash balance of £4.1m was a reduction of £1.4m compared to 2014/15, largely reflecting the impact of the Trust’s deficit.

Capital investment

During the financial year the Trust invested significantly in a capital programme totalling £10.4m on the facilities, equipment and technology used by the Trust to deliver healthcare, of which £1.4m was financed through leases.

Trust physical estate infrastructure again remained by far the largest area of investment. This was targeted toward prioritised risk-based investment to ensure operational buildings remained safe, fit for purpose, and compliant with statutory legislation.

The Trust received funding through the North West London Shaping a Healthier Future programme to invest prior to the anticipated


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order to minimise the organisation’s impact on the environment. A key element of the Sustainable Development Management Plan is to reduce the Trust’s energy use. The Carbon Reduction Commitment Energy Efficiency Scheme (often referred to as ‘the CRC’) is a mandatory scheme aimed at improving energy efficiency and cutting emissions in large public and private sector organisations. The scheme features a range of reputational, behavioural and financial drivers, which aim to encourage organisations to develop energy management strategies that promote a better understanding of energy usage.

With increased electrical demand from rising clinical activity and the addition of a new 48 bed Acute Medical Unit,

initiatives; and evidence that the supplier’s procurement is conducted in an ethical manner that is compliant with current legislation and takes account of relevant environment and sustainability standards. The Trust’s contracts with suppliers contain clauses relevant to these issues.

The Trust continues to make progress in its commitment to realising the benefits arising from carbon management, reducing harmful impacts to the environment, improving efficiency and resilience in the way that we operate our hospitals, and promoting the health and well-being of staff and the local population.

The Trust is refreshing the Sustainable Development Management Plan in

additional funding for a number of one-off investments to reduce overall running costs. These include:

> Sector-wide pathology joint venture start-up and transition costs

> Interim A&E expansion

> Health-economy outpatient prescribing transformation

> Hospital electronic prescribing

> Electronic document management.

Given its age and condition, managing the Trust’s estate infrastructure is an ever increasingly difficult and expensive task. The cost of maintaining current facilities to meet compliance standards and service requirements remains high.

Environmental issues

The Trust is committed to acting as a good corporate citizen. All Trust tenders include a section for prospective suppliers to provide narrative on environmental, sustainability, and ethical issues relating to their offer. This includes information on the suppliers’ adherence to environmental standards and policies; information on carbon reduction

The Trust continues to make progress in its commitment to realising the benefits arising from carbon management, reducing harmful impacts to the environment, improving efficiency and resilience in the way that we operate our hospitals, and promoting health and well-being of staff and local population.


on improving waste segregation and processing and in the coming year’s programme there will be an increased drive to improve our recycling and reduce landfill working in partnership with the local authority.

The Trust also hosted a conference of waste experts across London and the South East to share good practice in the safe management of waste.

Green travel

The Trust has continued to promote green travel for staff and service users. A Travel Plan Co-ordinator was appointed to lead the work to undertake a range of initiatives to encourage green travel in liaison with the local authority. A major survey of how people travel to the Hillingdon Hospital site was undertaken using a nationally recognised standard system for data collection and analysis. The Trust was also successful in locating and leasing off-site parking spaces for staff working closely with two local organisations to utilise spare parking capacity they had available.

and thereby lower its associated carbon emissions. In addition, the Trust will benefit from a reduction in both direct energy costs and non-energy charges in the form of lower carbon levies, operational, maintenance, and service costs.

Waste reduction and minimisation

The Trust’s Waste Group has met on a regular basis during the year. Part of its role is to ensure waste is segregated, managed, recycled and disposed of effectively in line with the Department of Health publication ‘Safe Management of Healthcare Waste’ and ‘Waste Hierarchy’ of the Department for Environment, Food & Rural Affairs.

The Facilities waste & recycling service provides the safe collection, management and disposal of materials from our sites. This has been a challenge over the past year due to the high volume of occupied beds over the past year and this too has generated an increase in clinical and domestic waste.

There was a decrease in the amount of waste sent to landfill in comparison to the previous year. During the year there has been considerable focus

the electricity consumption for the period 2015/16 increased to 60,213 Gigajoules (GJ) from 57,517 GJ in 2014/15, an increase of almost 4.41%. In addition, total gas consumption for the year rose by 2.32% against 2014/15 figures. The Trust’s contract with SRCL (Part of Stericycle Inc.) to operate the incinerator based on The Hillingdon Hospital site ensures our clinical waste travels a minimal distance before entering the incinerator process. It helps minimise the impact on the environment in that the steam created from burning clinical waste is used to provide 70% of the energy needed to heat the radiators and provide hot water at Hillingdon Hospital, therefore significantly reducing our need for energy sources such as gas and oil. The incinerator takes most of the waste from Hillingdon, and clinical waste from Mount Vernon Hospital.

Looking ahead

On its energy efficiency journey, the Trust is keen to work with an approved energy efficiency organisation to fund and support energy projects in the NHS. Leveraging external expertise based on other commercial environmental projects, the Trust will be able to upgrade its energy infrastructure at no net cost. The benefits of this approach would be in the way of implementing turnkey projects via simplified procurement, and skilled advisors at reduced costs, funding options and guaranteed savings. The projects being considered include, but are not limited to:

> Feasibility of a Combined Heating and Power plant

> Lighting upgrades

> Electrical system enhancements

> Metering strategy and associated energy monitoring and targeting software

These initiatives will help the Trust become a more efficient user of energy

2012/13 2013/14 2014/15 2015/16

Total waste generated at Hillingdon and Mount Vernon Hospitals

1,363 tonnes

1,476 tonnes

1,881 tonnes

1,736 tonnes

Waste recycled 351 tonnes (26%)

437 tonnes (30%)

441 tonnes (23%)

409 tonnes (24%)

Clinical waste incinerated to produce steam that generated heat and hot water at Hillingdon Hospital

545 tonnes (40%)

537 tonnes (36%)

574 tonnes (31%)

659 tonnes (38%)

Waste sent to landfill 467 tonnes (34%)

502 tonnes (34%)

866 tonnes (46%)

668 tonnes (38%)


2

2 Accountability report


Carol Bode: Non-Executive Director

Carol was appointed in April 2012. Carol’s professional background is in organisational development and governance and she has 35 years’ experience operating in the commercial sector, public sector and not for profit sector in retail, customer services, financial services, health housing and education. Previous Directorships have included Non-Executive Chair at Southern Health NHS FT, Trustee of Foundation Trust Network Board, Corporate Director with General Motors Company and Director of The Costello School (an Academy Trust). Currently, Carol is Non-Executive Chair of Radian Housing Group, Independent Chair of Hampshire Safeguarding Adults Board, Associate Trainer with NHS Providers, Associate Director with The Rialto Consultancy and Senior Adviser to Newton Europe. Carol is also a serving

to chairing the Board of Hillingdon Hospitals, he chairs the Trust’s Charitable Funds Committee and the Board of Directors’ Nominations Committee. His term of office expires on 31 October 2017.

Katey Adderley: Non-Executive Director

Katey Adderley was appointed in December 2010. Katey is a former Director and Partner of Charterhouse Capital Partners, one of Europe’s largest private equity companies, where she worked for 11 years. Katey is also a Non-Executive Director of BPP University. She has a first class Honours degree in Economics from Cambridge University and a Master’s degree (distinction) in Economic Evaluation in Healthcare. Katey is a Chartered Management Accountant. Katey is Chair of the Trust’s Audit & Risk Committee. Her term of office expires on 30th November 2016.

Director’s Report 2015/16

Richard Sumray: Trust Chair

Richard Sumray was appointed in November 2014. Richard has been involved for over 30 years as a Non-Executive Director in the NHS and is an experienced Chair. He chaired NHS Haringey (Primary Care Trust) for ten years from 2001 to 2011 and during that period also chaired the Joint Committee of London PCTs that supported Healthcare for London and the significant reforms to stroke and trauma services. He was also a member of the London Health Commission for eight years. Richard is a magistrate and has been chairing family and youth courts for 25 years in inner London. He was chair of the London 2012 Forum working with the London Organising Committee of the Olympic Games and was a leading figure in sport in London, starting the work on an Olympic bid in the early 1990s. He currently chairs Alcohol Concern and recently stood down from the Chair of The National Centre for Circus Arts. He was also a member of the Metropolitan Police Authority for eight years. In addition

Board of Directors

As at 31st March 2016 the Board comprised six Non-Executive Directors, a Non-Executive Chairman

and six Executive Directors. One Non-Executive Director, Pradip Patel, resigned on 29 February and

so there has been a vacancy for one month, during the financial year 2015/16. Interviews for this

vacant Non-Executive Directorship were held on 12 April 2016 and a candidate was appointed.

Details of Board members as at 31st March 2016 are outlined below.


2.1 Honours degree in Pharmacy from the London School of Pharmacy and has an MBA from Nottingham University. He worked for Boots for over 34 years, of which the last 18 years were at senior and Board levels; where he was Managing Director for Boots Opticians and Executive Chairman following its merger with Dolland and Aitchison. Pradip was employed as Director of Healthcare Strategy for Walgreens Boots Alliance. He is a Fellow of the Chartered Institute of Management and a Member of the Royal Pharmaceutical Society of Great Britain. Pradip was the Trust’s Deputy Chair and Senior Independent Director, and was chair of the Board of Directors Remuneration Committee and Transformation Committee.

London Care Programmes and Co-Chair of the Integrated Care Programmes, Lis currently has a leading role in developing integrated care in North West London and has special responsibility for encouraging partnerships with people using health and social care services. Lis holds the ILM Diploma in Executive Coaching and Leadership Mentoring, and was named NHS Mentor of the Year 2010. In 2011 she received an OBE for services to Medicine. Lis is a Fellow of the Royal College of Physicians. Her term of office expires on 31st January 2017.

Pradip Patel: Non-Executive Director

Pradip Patel was appointed in August 2011. Pradip Patel resigned from the Trust on 29 February 2016 to become Chair of Frimley Park NHS Foundation Trust, and so was with the Trust for 11 out of 12 months in 2015/16. Pradip qualified with a First Class

magistrate in North Hampshire. Carol was appointed Deputy Chairman in March 2016, Chair of Remuneration Committee and the Board’s Quality & Safety Committee. Carol’s term of office expires on 31st March 2018.

Professor Soraya Dhillon MBE: Non-Executive Director

Soraya Dhillon was appointed in February 2014. Soraya is a clinical academic and Dean of School of Life and Medical Sciences at the University of Hertfordshire. Soraya has a PhD in clinical pharmacology and has held a number of key senior academic posts. Her research interests are in chronic disease management, prescribing, medicines optimisation and patient safety. Soraya is the former Non-Executive Chairman of Luton and Dunstable Hospital NHS Foundation Trust and a member of the General Pharmaceutical Council. Soraya is a fellow of the Royal Pharmaceutical Society and was awarded an MBE for her contribution to health services in Bedfordshire. Soraya brings expertise in strategic leadership, academia and patient safety to the Board. Soraya has been appointed Chair of the Board’s Transformation Committee from March 2016, a member of the Board’s Audit & Risk Committee and Quality and Safety Committee. Soraya’s term of office expires on 31st January 2017.

Professor Elisabeth (Lis) Paice OBE: Non-Executive Director

Lis Paice was appointed in February 2014. Lis trained as a doctor at Trinity College Dublin and Westminster Medical School before being appointed as a Consultant Rheumatologist at the Whittington Hospital. For 15 years Lis was Dean Director of London Deanery, overseeing the postgraduate training of doctors. Previously Chair of the Inner and Outer North West


was awarded the Florence Nightingale leadership scholarship for 2012, she is an Honorary Professor for the City of London University, and has an LLB. Theresa holds Board level responsibility for nursing, governance and risk management, infection prevention and control, safeguarding people, patient experience and engagement.

David Searle: Director of Strategy & Business Development

David Searle was appointed in 2007. David had a 20 year career in the Royal Navy as a Fleet Air Arm pilot, where senior roles included second in command of a major Air Defence warship and the Commanding Officer of a large front line Naval Air Squadron. David subsequently worked in the aerospace and defence industries where he held senior positions in procurement, commercial management, business development and marketing. He was latterly Director, Wider Markets in the Defence Aviation Repair Agency before joining the Trust. David has Board level responsibility for estates and facilities, business development, strategy, business planning, communications and marketing. He is a Trustee of St David’s Care Home for ex-servicemen and women.

Joe Smyth: Chief Operating Officer

Joe Smyth was appointed Chief Operating Officer in March 2015; having previously been the Trust’s Director of Operational Performance. Joe has over 20 years senior managerial healthcare experience, including Deputy Chief Operating

& St Helier University Hospitals NHS Trust. Australian by birth, he began his healthcare career in 1990 after training as a Physiotherapist in Adelaide, South Australia. Shane has been appointed by the Board as the Trust’s Director of Imperial College Health Partners, and is also a Board member of the North West London Local Education & Training Board (a sub-committee of Health Education England), which is a Non-Executive role.

Dr Abbas Khakoo: Medical Director

Abbas Khakoo was appointed as Medical Director in October 2014 having held the position on a job-share basis since in January 2013. Abbas is a Consultant in Paediatrics and the care of new born babies. Abbas also runs a children’s allergy service at Hillingdon Hospital and at St Mary’s Hospital, part of Imperial College Healthcare NHS Trust. Since July 2015, Abbas has been the Chair of the Paediatric Project Delivery Board and Joint Senior Responsible Officer for the Paediatric Transition, Shaping a Healthier Future.

Professor Theresa Murphy: Director of the Patient Experience & Nursing

Theresa joined the Trust in May 2013 having been the Director of Nursing at North Middlesex University Hospital NHS Trust. Theresa qualified in general nursing in 1987, before specialising in Neuroscience and Critical Care nursing. Theresa has also held a number of clinical and managerial posts in both teaching and general hospitals. Theresa

Richard Whittington: Non-Executive Director

Richard Whittington was appointed on 1st October 2014. Richard is a chartered accountant (FCA) who was a Senior Partner at KPMG, where he was latterly in charge of the Infrastructure, Government and Healthcare Audit Group which provided audit services to the health and public sectors and building and construction companies. Richard is Non-Executive Director and Chairman of the Audit Committee at ISG Plc, a £1.4 billion turnover international construction services group, and Chairman of ISG Middle East LLC. Until January 2015 he was Chairman of the Magstim Company Limited, a high-tech business in the neuro-science field. Richard is a Director, Trustee and Honorary Treasurer of the Community Foundation of Surrey and Chair of Governors and Director of the Gordon’s School Academy Trust Limited and a Trustee of the Gordon Foundation. Richard was appointed High Sheriff of Surrey from April 2016. Richard brings senior financial, audit and corporate governance experience to the Board, together with estates and capital investment expertise. Richard is chair of the Capital Investment Committee and a member of the Audit and Risk and Transformation Committees. Richard’s term of office expires on 30th September 2017.

Shane DeGaris: Chief Executive

Shane DeGaris was appointed Trust Chief Executive in May 2012 having previously been the Trust’s Deputy Chief Executive & Chief Operating Officer. Shane is an experienced NHS Director having worked in a number of London Trusts in senior management roles including as Director of Operations at Barnet & Chase Farm Hospitals NHS Trust and as Deputy Chief Executive at Epsom


2.1 spent almost all his working life within the NHS, including working in performance management for the NHS in London. Paul also held Board level responsibility for purchasing and supplies; the Trust’s information services and information technology functions, which includes the clinical coding team; health and safety; and was the Trust’s Senior Information Risk Owner (SIRO).

Trevor Mayhew: Acting Finance Director (from 16 February 2016)

Trevor Mayhew was appointed Interim Finance Director from 15th February to 3rd April 2016. Trevor is a member of the Association of Chartered Certified

Officer at Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and Director of Service Improvement at Epsom and St Helier University Hospitals NHS Foundation Trust. Joe holds Board-level responsibility for the management of the clinical divisions, emergency planning, Integration and the QIPP programme (Quality, Innovation, Productivity and Prevention). One of Joe’s key responsibilities is to ensure that the Trust meets and exceeds all national and local patient access standards.

Paul Wratten: Finance Director (to 15 February 2016)

Paul Wratten was appointed Finance Director in 2000. Paul is a member of the Chartered Institute of Public Finance and Accountancy, and has

Accountants, and has spent all his working life within the NHS, with previous positions at Royal Free and Great Ormond Street Hospitals. Trevor has worked at the Trust since April 2000, and has been the substantive Deputy Director of Finance since May 2002. Trevor also held Board level responsibility for purchasing and supplies; the Trust’s information services and information technology functions, which includes the clinical coding team; health and safety; and is the Trust’s Senior Information Risk Owner (SIRO).


Financial Reporting Council and our external auditors, reviewed the Board’s Committees’ terms of reference. This review sought to give enhanced emphasis to areas which the Board deemed priorities: capital investment, risk and patient safety. The review also clarified the roles of individual committees to avoid duplication and to make their remit more manageable. The Board agreed that:

> Quality and Risk Committee become the Quality and Safety Committee in order to give increased emphasis to patient safety

> Audit and Assurance Committee become the Audit and Risk Committee

> The Capital Investment Group become a Committee of the Board, known as the Capital Investment Committee.

These changes came into immediate effect.

Board members’ other commitments and Register of Interests

Company directorships and other significant commitments held by Board members are outlined above. Board members are required to enter their relevant interests in the Register of Directors’ Interests which is formally reviewed by the Board annually. The full register is available from the Trust Secretary on 01895 279976.

Statement on the balance, completeness and appropriateness of the membership of the Board

The Board of Directors Nominations Committee is responsible for reviewing the structure, size and composition of the Board and makes recommendations to the Council of Governors on the skills required for any upcoming Non-Executive Director appointments. As outlined in the biographies of Board members, the Board comprises individuals with senior level experience in the public and private sectors, across a range of disciplines including clinical and patient care; health service leadership; commercial development; business transformation and change management; finance; governance; risk management; and human resources. The Board therefore confirms that the current composition is considered to be appropriate. Taking account of the NHS Foundation Trust Code of Governance published by Monitor, the Board considers the current Chairman and all of the Non-Executive Directors to be ‘independent’.

Performance evaluation of the Board Committees

In October 2015 the Board, in line with good practice in corporate governance as recommended by Monitor, the

In attendance at Board meetings:

Claire Gore: Director of People (to 29 February 2016)

Claire Gore joined the Trust in 2010 as Director of People. Claire attended Board meetings in a non-voting capacity. Claire is a Fellow of the Chartered Institute of Personnel and Development (FCIPD) and has worked at a senior level in human resources and training and development in a number of public sector organisations including the London Borough of Brent and the Metropolitan Police Service. Claire had Board level responsibility for human resources (including recruitment, employee relations and temporary staffing), occupational health, nurse training, and workforce and organisational development.

Terry Roberts: Director of People and OD (from 1 March 2016)

Terry joined the Trust in March 2016 as Director of People and Organisational Development and attends Board meetings in a non-voting capacity. Prior to this post he was the Director of Workforce at Kingston Hospital Foundation Trust and has held senior HR positions at Bart’s Health, Ealing Hospital, St Mary’s Hospital and North West London Hospital as well as working at the Department of Health as a National HR Advisor. Terry holds a Master’s Degree in Human Resources Management and is a Fellow of the Chartered Institute of Personnel and Development (FCIPD). He has completed the Top Managers Programme with the Kings Fund and is a certified Coach and Mediator. Terry has Board level responsibility for human resources (including recruitment, employee relations and temporary staffing), occupational health, nurse training, and workforce and organisational development.

As outlined in the

biographies of Board members,

the Board comprises individuals with

senior level experience in the public and

private sectors, across a range of disciplines

including clinical and patient care; health

service leadership; commercial development;

business transformation and change

management; finance; governance;

risk management; and human

resources.


2.1 The audit fee for 2015/16 was £79,000 plus VAT (£64,500 plus VAT for the financial statement audit and £14,500 plus VAT for work on the quality report).

In October 2013 the Council of Governors agreed an updated policy

has independent and effective internal and external audit functions.

External auditThe Audit & Risk Committee (ARC) is responsible for making recommendations to the Council of Governors on the appointment and removal of the external auditor. In October 2013 the Council of Governors appointed Deloitte as the Trust’s external auditors for a three year period starting with the 2013/14 audit with an option for two one year extensions.

In line with the Code of Governance this reappointment is subject to annual review. This annual review involves the Audit & Risk Committee (ARC) members completing a structured review of external audit against the areas of work set out in Monitor’s Audit Code:

> Financial statements

> Annual governance statement

> The Trust’s arrangements for securing economy, efficiency and effectiveness in the use of resources; and

> The quality report.

Plus review of external audit against 46 criteria across the following domains:

> The audit partner

> The audit team

> The audit approach – planning and then execution

> Communications by the auditor to the ARC

> External audit’s support to the work of the ARC

> Insights and adding value

> Formal reporting by the auditors.

The Chair of the ARC then presents a report to the July meeting of the Council of Governors on the outcomes of this review and whether external audit’s appointment should be confirmed.

Meetings of the Board, its Committees and the Council of Governors in 2015/16

The Board

The Board met 12 times during 2015/16. The Board comprises of a Non-Executive Chairman, six Non-Executive Directors and five Executive Directors. The Director of People is also in attendance. In order to make Board meetings accessible to the public and Governors, four Board meetings were held at Mount Vernon Hospital and eight at Hillingdon Hospital. Two of the meetings at Hillingdon Hospital were held at 5pm.

Audit & Assurance Committee, becoming Audit & Risk Committee in October 2015

The Audit & Risk Committee (ARC)met five times during 2015/16. As at 31st March 2016, the Trust’s Audit & Risk Committee comprises four Non-Executive Directors (one vacancy from 29 February 2016); two of whom (including the Committee Chair) have recent and relevant financial experience. The Committee is usually attended by the internal and external auditors, the Finance Director and the Director of Patient Experience & Nursing as the Executive Director responsible for clinical and corporate governance. The Local Counter Fraud Specialist attends at least two meetings a year, and other directors and senior managers attend when invited by the Committee.

The Committee is responsible for providing an independent and objective review of the Trust’s systems of internal control (both financial and non-financial) and the underlying assurance processes in place at the Trust. The Committee is also responsible for ensuring that the Trust

Committees of the BoardThe Board has seven committees:

1 Audit & Risk Committee

2 Quality and Safety Committee

3 Transformation Committee

4 Capital Investment Committee

5 Board of Directors Nomination

Committee

6 Board of Directors Remuneration

Committee

7 The Charitable Funds Committee

Each of these is chaired by a Non-Executive Director.


on the engagement of the external auditors to undertake additional services. Under this policy, any such work is reported to the Council of Governors. No such additional work was commissioned in 2015/16.

Internal auditThe Trust’s internal audit service is provided by TIAA (The Internal Audit Agency). During 2015/16 the Trust followed good practice and market tested its contract for internal audit. KPMG has been appointed and will provide internal audit services from July 2016.

Internal audit provides an independent and objective opinion on risk management, control and governance by measuring and evaluating the effectiveness by which organisational objectives are achieved. Through detailed examination, evaluation and testing of the Trust’s systems, internal audit play a key role in the Trust’s assurance processes. The scope and

work of the Trust’s internal auditors, is set out in a charter approved by the Audit & Risk Committee.

The Audit & Risk Committee agree a work plan for internal audit at the start of each financial year, taking account of the risk assessment undertaken by internal audit. The Committee review the findings of internal audit’s work against this plan at its quarterly meetings. Audits undertaken in 2015/16 included: medicines management, health and safety and financial reporting and budgetary control.

The Head of Internal Audit reports to the Committee and is managed by the Finance Director. The Head of Internal Audit has a right of direct access to Committee members.

Key issues considered by the CommitteeKey elements of the Committee’s work include reviewing the Board Assurance Framework, the Risk Register, the

Trust remaining a going concern and reviewing the findings of the Trust’s internal and external auditors and Local Counter Fraud Specialist. The Committee is responsible for reviewing the annual financial statements, with particular focus given to major areas of judgement and changes in accounting policies, determining that the Trust remains a going concern, and reviewing the draft annual report including the annual governance statement. The Committee also reviews the assurance in place in respect of data quality.

In addition the Committee monitored estates compliance, the data universe, compliance with information governance standards, reviewed contingent liabilities, reviewed debtors and examined the Trusts’ processes for securing value for money, economy, efficiency and effectiveness in its use of resources.


2.1 Quality and Risk Committee that became Quality and Safety Committee in October 2015

The Quality and Safety Committee met five times during 2015/16. As at 31st March 2016, the Trust’s Quality & Safety Committee comprises four Non-Executive Directors and four Executive Directors. The Committee’s remit is to review the clinical divisions in relation to the clinical governance and quality agenda including what arrangements they have put in place to make any necessary improvements. Review and challenge clinical quality and patient safety and ensure that action plans are developed and implemented to address any areas of concern. The Committee also monitors the Trust’s compliance with Care Quality Commission registration requirements.

Key issues considered by the CommitteeThe Committee is developing a Quality and Improvement Strategy to drive improved quality of service and to ensure patient focus. Divisional quality performance reporting is to be aligned to provide improved analysis and triangulation of data. A deep dive review to achieve no preventable deaths was undertaken; particularly looking at narrowing the death rate between weekday and weekends; and considerable progress has been made in reducing the weekend death rate. There has been focus on A&E nursing and leadership, understanding why there are gaps in the nursing workforce at Band 6 and 7 and ensuring there are sufficient staff of the appropriate skill-mix in maternity.

Transformation Committee meetings in 2015/16

The Transformation Committee met four times during 2015/16. As at 31 March 2016, The Trust’s Transformation Committee comprises

of three Non-Executive Directors and five Executive Directors. The Committee’s remit is to shape, challenge and review the development and implementation of the Trust’s transformation programme with a particular focus on the multi-year schemes that improve quality whilst reducing cost.

Key issues considered by the CommitteeThe work of the Committee has focused on the Trust’s need to identify £50.7m of recurrent savings over the period from 2014/15 to 2020/21. £8m of savings in 2015/16 have been made; which although is a considerable achievement, is £1.5m below its target; so targets for subsequent years have been revised to re-coup this shortfall. The Committee also focused on developing a workforce transformation programme; this includes working with HENWL (Health Education North West London) to develop workforce models to better meet the needs of the Trust in terms of skills and future workforce requirements.

Capital Investment Group that became the Capital Investment Committee in October 2015

The Capital Investment Committee met eight times during 2015/16. As at 31 March 2016, The Trust’s Capital Investment Committee comprises of two Non-Executive Directors and four Executive Directors. The Committee’s primary remit is to shape, challenge and review the development and implementation of the Trust’s strategic redevelopment programme.

Key issues considered by the CommitteeThe Committee appointed master planners in September 2015 to develop detailed options for hospital development at both the Hillingdon and Mount Vernon sites. Phase 1 has involved data gathering and identifying

options; this has included working with our CCG. The Committee is leading negotiations with East and North Hertfordshire NHS Trust on future land use at Mount Vernon. The Capital Investment Committee also monitored the capital investment programme for 2015/16 and identified priorities for capital spending for 2016/17. Schemes that have been prioritised are improvement to the building infrastructure, repairing what is needed and purchasing medical equipment.

Board of Directors Nominations Committee meetings 2015/16

The Board of Directors Nomination Committee met three times during 2015/16. As at 31 March 2016, the Trust’s Board of Directors Nomination Committee comprises of seven Non-Executive Directors (one vacancy from 29 February 2016) and is attended by the Director of People and Organisational Development. The Board of Directors Nomination Committee leads the process for Board appointments.

Key issues considered by the CommitteeDuring 2015/16, the Committee recruited and appointed a new Director of Finance and a new Director of People and Organisational Development. The Committee also reviewed the succession pipeline and agreed that the Trust should focus on developing staff that have the ability to take on director-level posts in the next three years.


Key issues considered by the CommitteeThe Committee actively reviewed income and expenditure within the fund and the performance of the fund managers, Brewin Dolphin. An Annual Report and Accounts were produced, reviewed and lodged with the Charity Commission. The Committee recruited a Charity Director, who is paid through the fund, to lead the work of the Charity. Also in 2015/16 the Committee worked on developing an ethical investment strategy in line with good practice as stated by the Association of NHS Charities, which will be published in July 2016. The Committee reviewed bids for allocation of funds; and of particular note, approved the purchase of mannequins for the Simulation Centre including the SimMom, a mannequin for obstetric training.

Charitable Funds Committee meetings 2015/16

The Charitable Funds Committee met three times during 2015/16. As at 31 March 2016, the Trust’s Board of Directors Charitable Funds Committee comprises of three Non-Executive Directors and two Executive Directors. The Charitable Funds Committee assists the Trust in its role as corporate trustee for The Hillingdon Hospitals NHS Foundation Trust charity and has been established to make and monitor arrangements for the control and management of the Trust’s charitable funds. Rekha Wadhwani (Lead Governor) joined the Committee in October 2015.

Board of Directors Remuneration Committee meetings 2015/16

The Board of Directors Remuneration Committee met three times during 2015/16. As at 31 March 2016, the Trust’s Board of Directors Nomination Committee comprises of seven Non-Executive Directors (one vacancy from 29 February 2016). This Committee is attended by the Chief Executive and the Director of People and Organisational Development. This Committee sets executive pay, based on a thorough appraisal of executive performance.

Key issues considered by the CommitteeThe Committee formally appraised the Chief Executive and all Executive Directors, agreed their pay and set performance targets for 2016/17.


2.1 Attendance at Board and Board Committee meetings

The following table outlines Board members’ attendance at Board and Committee meetings during 2015/16 against the total possible number of meetings for which an individual was a member. Committee attendance is shown in relation to those Committees of which a Director is a formal member.

Board of

Directors

(12

meetings)

Audit & Risk

Committee

(5 meetings)

Board

Nominations

Committee

(3 meetings)

Board

Remuneration

Committee

(3 meetings)

Charitable

Funds

Committee

(3 meetings)

Quality

& Safety

Committee

(5 meetings)

Transformation

Committee

(3 meetings)

Katey Adderley 12/12 5/5 1/3 2/3 2/3 5/5

Carol Bode 10/12 1/3 2/3 2/3 5/5 2/3

Shane DeGaris 12/12 3/3 3/3 3/3

Soraya Dhillon 11/12 5/5 3/3 2/3 5/5 2/3

Abbas Khakoo 11/12 4/5 1/3

Theresa Murphy 12/12 5/5 2/3

Lis Paice 11/12 1/3 3/5

Pradip Patel 11/11 5/5 2/3 3/3 3/3

David Searle 12/12 2/3

Joe Smyth 11/12 2/5 2/3

Richard Sumray 12/12 3/3 3/3 3/3 3/3

Richard

Whittington

11/12 5/5 2/3 3/3 3/3

Paul Wratten 10/10 3/3 3/5 3/3

Trevor Mayhew

(Acting Finance

Director)

2/2


Council of GovernorsThe role and powers of the Council of Governors are outlined earlier in the report. The composition of the Council of Governors is outlined in the Trust’s Constitution.

As at 31 March 2015 there were 24 positions on the Council of

Name Date took office and method (see key below)

Term of office expires

Public Governors

North (4) Graham Bartram 01/04/2014 (CE) 31/03/2017

Ian Bendall 01/04/2014 (CE) 31/03/2017

David Bishop 01/04/2014 (CE) 31/03/2017

Tony Ellis 01/04/2014 (CE) 31/03/2017

Central (4) Harkishan Chander 01/04/2014 (CE) 31/03/2017

Donald Dakin 01/04/2014 (CE) 31/03/2017

Terry Thompson 01/07/2015 (CE) 30/06/2018

Roger Shipton 01/04/2014 (CE) 31/03/2017

South (4) Raymond Smith 01/03/2016 (CE) 28/02/2019

Keith Saunders 01/04/2014 (CE) 31/03/2017

Doreen West 01/04/2014 (CE) 31/03/2017

Rekha Wadhwani 01/04/2014 (CE) 31/03/2017

Rest of England Daphne Magidi 01/07/2015 (CE) 30/06/2018

Staff Governors

Doctors & Dentists (1) Alvan Pope 01/04/2014 (UE) 31/03/2017

Nurses, Midwives, Healthcare Assistants (3) Sheila Bacon 08/04/2014 (UE) 31/03/2017

Sheila Kehoe 08/04/2014 (UE) 31/03/2017

Amanda O’Brien (resigned 31/3/2016)

01/04/2014 (UE) 31/03/2017

Allied Health Professionals (1) Graham Coombs 01/04/2014 (CE) 31/03/2017

Support Staff (2) Paul Cornford 01/04/2014 (UE) 31/03/2017

Jack Creagh 01/04/2014 (UE) 31/03/2017

Appointed Governors

Hillingdon Clinical Commissioning Group (1) Dr Mayur Nanavati 01/04/2014 (A) 01/04/2017

London Borough of Hillingdon (1) Mary O’Connor 01/04/2014 (A) 01/04/2017

London Ambulance Service (1) Pauline Cranmer 01/04/2014 (A) 01/04/2017

Joint Negotiating & Consultative Committee (1) Nicola Batley 01/07/2015 30/06/2018

Key: CE – contested election UE – uncontested election A – appointed by partner organisation

Governors: 13 elected to represent the public members, seven elected to represent the staff members, and four appointed by partner organisations (Hillingdon Council, Hillingdon Clinical Commissioning Group, the London Ambulance Service, and the Trust’s Joint Negotiating & Consultative Committee).

The members of the Council of Governors who served during 2015/16 are outlined below.


2.1 the Council of Governors on an issue for which the normal channels of communication are not appropriate.

> Be the conduit for raising with Monitor any Governor concerns that the Foundation Trust is at risk of significantly breaching its Licence, having made every attempt to resolve any such concerns locally.

> Chair such parts of meetings of the Council of Governors which cannot be chaired by the Trust Chair or Deputy Chair due to a conflict of interest in relation to the business being discussed.

In September 2015 John Coleman resigned as Lead Governor. An election was held in November 2015; the Council of Governors elected Rekha Wadhwani as their Lead Governor for the remainder of 2015/16 and for the 2016/17 financial year.

Council of Governors Nominations & Remuneration Committee

The Committee met three times during 2015/16. The Committee comprises of the Chairman of the Trust, three public Governors and two staff Governors. The Council of Governors Nomination & Remuneration Committee leads the process for appointing the Chairman and all Non-Executive Directors; it is also responsible for agreeing their remuneration, appraising their performance and setting their targets.

The Committee’s main areas of work during the year were to appraise the Chairman and Non-Executives, agree their remuneration and set their targets. Pradip Patel announced his resignation in November 2015

Governor Meetings attended

Graham Bartram (Public) 4 of 4

Ian Bendall (Public) 3 of 4

David Bishop (Public) 4 of 4

Tony Ellis (Public) 4 of 4

Harkishan Chander (Public) 3 of 4

Donald Dakin (Public) 3 of 4

Raymond Smith (Public) Started March 2016

Roger Shipton (Public) 4 of 4

John Coleman (Public) 3 of 3

Keith Saunders (Public) 4 of 4

Rekha Wadhwani (Public) 4 of 4

Doreen West (Public) 3 of 4

Terry Thompson (Public) 1 of 2

Daphne Magadi (Rest of England) 2 of 2

Alvan Pope (Staff) 3 of 4

Sheila Bacon (Staff) 4 of 4

Sheila Kehoe (Staff) 3 of 4

Amanda O’Brien (Staff) 4 of 4

Graham Coombs (Staff) 4 of 4

Paul Cornford (Staff) 2 of 4

Jack Creagh (Staff) 4 of 4

Dr Mayur Nanavati (Appointed) 2 of 4

Mary O’Connor (Appointed) 4 of 4

Pauline Cranmer (Appointed) 1 of 4

Nicola Batley (Appointed) 1 of 3

Rachel Hyman (Appointed) 1 of 1

In 2015/16 the Council of Governors formally met four times. Governor attendance at these meetings is outlined below. Where a Governor was not in office for all four meetings, the maximum possible attendance is shown below.

Governors are required to declare any relevant interests which are then entered into the publicly available Register of Governors’ Interests. The Register is formally reviewed by the Council of Governors annually and is available from the Trust Secretary on

01895 279976. The postal address is Trust Secretary, The Hillingdon Hospital, Pield Heath Road, Uxbridge, Middlesex UB8 3NN.

Lead Governor

In line with Monitor’s Code of Governance, the Council of Governors elects one of the Public Governors to be the ‘Lead Governor’. The main duties of the Lead Governor are to:

> Act as a point of contact for Monitor should the Regulator wish to contact


Governors and members. Throughout the year the Chairman and each Non-Executive Director has addressed the Council of Governors outlining their experience, and what they are focusing on at the Trust. In addition a monthly briefing session for Governors is held with the Chairman where Governors are updated on matters at the Trust and have the opportunity to ask questions of the Executive Directors.

The Council of Governors meetings are held in public and there is an opportunity for members of the public to ask Governors and members of the Board questions. Governors and Members of the Board also attend the Trust’s People in Partnership meetings and Annual Members Meeting to liaise with members and Governors.

Attendance by Board members at the four meetings of the Council of Governors and the joint meeting between the Board and Council of Governors in 2015/16 is outlined below.

(and left the Trust on 29 February 2016); the Committee oversaw the appointment processes for the vacant Non-Executive Director (NED) position. The Committee engaged the executive search agency, Gatenby Sanderson, to assist with these processes.

Pradip Patel was both Deputy Chairman and Senior Independent Director; the Committee deliberated on how best to fill these roles and appointed Carol Bode to be the Deputy Chairman of the Trust and Lis Paice to be the Senior Independent Director. Both began their roles from 1 March 2016.

The Committee’s work in relation to non-executive remuneration is outlined in the remuneration report.

The Board’s liaison with Governors and members

All Board members have a standing invitation to attend Council of Governors meetings in order to ensure they understand the views of

Board Member No of Council of Governor meetings attended in 2015/16 (4 meetings held)

Katey Adderley (Non-Executive Director) 3 / 4

Carol Bode (Non-Executive Director and Deputy Chair from 1 March 2016) 3 / 4

Shane DeGaris (Chief Executive) 4 / 4

Soraya Dhillon (Non-Executive Director) 4 / 4

Abbas Khakoo (Medical Director) 1 / 4

Theresa Murphy (Director of the Patient Experience & Nursing) 2 /4

Lis Paice (Non-Executive Director – and Senior Independent Director from 1 March 2016)

3 /4

Pradip Patel (Deputy Chair, Senior Independent Director & Non-Executive Director – left the Trust on 29 February 2016)

4 / 4

David Searle (Director of Strategy & Business Development) 3 / 4

Joe Smyth (Chief Operating Officer) 2 / 4

Richard Sumray (Chair) 4 / 4

Richard Whittington (Non-Executive Director) 2 / 4

Paul Wratten (Finance Director) 3 / 4

The Council of Governors

meetings are held in public and there

is an opportunity for members of the

public to ask Governors and members

of the Board questions.

?


2.1 Public membership

There are four public constituencies, which are collectively known as the Public Constituency. The majority of the public members are drawn from the three public constituencies which cover the electoral wards in Hillingdon borough together with several neighbouring electoral wards. The fourth public constituency covers all other electoral areas in the rest of England. Public membership is open to individuals aged 16 years or over living within the Public Constituency, who are not eligible to be a staff member of the Foundation Trust. The Constitution includes two further disqualifications on public membership.2

Staff membership

The staff constituency is a single constituency divided into the following classes:

> Doctors and dentists

> Nurses and midwives (including health care assistants)

> Allied Health Professionals

> Support staff.

Staff membership is open to all those employed by the Trust on a permanent basis, those who have a fixed term contract of at least 12 months, and those who have been working at the Trust for at least 12 months. These staff are automatically members of the

2. An individual may not become or remain a member of the Trust if during the five years prior to their application, they have demonstrated aggressive or violent behaviour at any hospital or towards any person working for a health service body and following such behaviour has been excluded from any hospital or other health service body under either the Trust’s or other health service body’s policy for withholding treatment from violent/aggressive patients, or equivalent. Nor can anyone become or continue as a member of the Trust if they have been confirmed as a ‘vexatious complainant’ in accordance with the Trust’s complaints handling policy.

Membership

The Foundation Trust membership is divided into two categories: public membership and staff membership.


and engages with a representative membership. It outlines our plans for raising awareness about membership and for the recruitment, retention and involvement of members. It also defines how we will measure the success of the strategy. The strategy was produced with the guidance and input of the Council of Governors.

The Hillingdon Hospitals NHS Foundation Trust is committed to recruiting members from the diverse population served by the Trust. Membership is open to all those eligible to be a member regardless of gender, race, disability, ethnicity, religion or any other groups covered under the Equality Act 2010. The membership base is regularly reviewed to ensure that the membership is representative of those eligible to be members. Specific groups that appear to be under-represented are targeted in recruitment campaigns in order to seek to increase membership representation in these areas, such as young people between the ages of 16 and 45.

redesigning the welcome letter to be sent to new members from the Governors, and encouraging Governors to suggest content for the Pulse Foundation Trust newsletter.

Staff Membership as at 31 March 2015

As at 31 March 2016 the Trust had 3600 staff members. The following table provides a breakdown by staff group. Each staff group includes bank staff who meet the Trust’s eligibility criteria for staff membership:

Staff Class Number of members

Doctors and Dentists

473

Nurses, Midwives & Healthcare

1492

Allied Health Professionals, Scientific and Technical

515

Support staff 1072

Total 3552

Membership Development and Engagement Strategy (not yet approved by the Trust Board)

The Trust with the Council of Governors has updated and approved the Membership Development and Engagement Strategy at its meeting in February 2016. The Strategy describes the Trust’s objectives for the membership and the approach we will use to ensure the Trust develops

Staff Constituency unless they ‘opt-out’ from membership. In addition, those working at the Trust through the temporary staffing ‘bank’ become staff members providing they have been registered on the Trust’s bank for at least 12 months and continue to be registered. So far no staff have opted out from being a member of the Foundation Trust.

Staff membership will cease at the point that the member leaves the service of the Trust. Anyone eligible to be a staff member of the Foundation Trust cannot be a public member.

Public Membership as at 31 March 2016

As at 31 March 2016, the Trust had 6,976 public members. The table below illustrates the number of public members for each constituency compared to the total population.

During 2015/16, the Foundation Trust recruited 203 new public members and lost 263 public members due to bereavement, moving away without providing a new address or cancelling their membership.

The Trust has established a Council of Governors Membership Development and Engagement Group to enable Governors to become engaged in a programme of focused recruitment and engagement with members. Key actions agreed by the group included setting up Governor surgeries in the hospital, identifying community events for the Governors to attend,

31 March 2016 % of membership Population Base % of area

Central 2622 37.6 192,514 39.7

North 1360 19.5 103,738 21.4

South 2715 38.9 188,793 38.9

Rest of England

279 4.0 0 0

Total 6,976 0 0 0


2.1 Key actions to grow membership and improve engagement:

> Encourage Governors to attend local groups and events (e.g. Resident Associations and Community Voice) to engage with the public and recruit new members

> Support fund-raising events organised by the Trust or other local organisations

> Attract new members visiting the hospitals during monthly Governor/member surgeries

> Organise membership recruitment events at Hillingdon and Mount Vernon Hospitals

> Encourage Governors and members to sign up family, friends and members of the public

> Promote membership with staff working for the London Borough of Hillingdon

> Invite ex-staff, their family and friends to become public members

> Utilise existing networks in promoting membership with staff and students at local universities and schools

> Encourage all volunteers to sign up as public members

> Use social media (e.g. Twitter) to attract new members.


2.1

service in England must be greater than its income from the provision of goods and services for any other purposes. In 2015/16, the Trust met this requirement, with 96.9% (£231m) of the Trust’s income generated by activities for the purpose of the health service in England.

As the vast majority of Trust income is categorised as generated by activities for the purpose of the health service in England, it is the Board’s view that other income does not detract from NHS provision to any material extent. Where other income is generated it supports the Trust to make optimum use of its assets and is used to directly support principal patient care activities.

Directors’ Disclosure to Auditors

For each individual who was a director at the time that this report was approved:

> So far as the director was aware, there was no relevant audit information of which the NHS Foundation Trust’s auditor was unaware and

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

Trust’s policy on the involvement of members, patients and wider public, including a statement on the Trust’s approach to consultation, and addressing the overlap and interaction between the Governors and other consultative and representative groups. The strategy is available on the Trust’s website. Political Donations

The Trust has not made any donations to political parties.

Payment of creditors

The Trust aims to comply with the Better Payment Practice Code which is that 95% of invoices in terms of numbers and value are paid by the due date of payment, though has been unable to achieve the target in 2015/16. Details of the Trust’s compliance in this matter can be found in note 7.1 of the accounts. The Trust paid out £3k in 2015/16 for interest on late payments under the Commercial Debts (Interest) Act 1998 (£10k in 2014/15).

Income Disclosure

Section 43 (2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) requires that the Trust’s income from the provision of goods and services for the purposes of the health

Engagement between Governors and members

They are preceded by an opportunity for members and Governors to meet over refreshments. The Trust encourages and facilitates linkages between the Council of Governors and groups and organisations which represent patients, public and the wider community. During 2015/16, Public Governors attended various community events throughout the year, including the May Fair in West Drayton, RAF Northolt Centenary Open Day, Ruislip Manor Fun Day and the Harmondsworth and Sipson Open House. Many Governors participate in activities unrelated to health i.e. local churches, volunteer driving and education and are therefore able to communicate with local residents and public members at these events and report back to the wider Council of Governors in order to ensure that the Council of Governors is aware of public comments and concerns which have been raised.

The Trust provides Governors with information on the Trust’s strategy and performance at various meetings such as the formal quarterly Council of Governors meetings, monthly informal meetings with the Chair and Chief Executive, and the joint meetings between the Board and Council of Governors. Governors can then feed this information back to the members and organisations they represent. These meetings also provide the opportunity for Governors to feedback issues of concern raised by members. During 2015/16 such issues included car-parking at the Hillingdon site, staffing, and the estate. Governors are also able to communicate with members through the quarterly members’ newsletter – ‘The Pulse’ which regularly features a Governor article.

The Membership Development & Engagement Strategy outlines the

The Trust organises ‘People in Partnership’ meetings which enable the Governors, particularly the Public Governors, to engage with the members they represent. The meetings are held at a variety of locations four times during the year and are chaired by a Governor.


2.2 Remuneration report


2.2 The Trust’s pay policy is to set executive remuneration between the median and upper quartile of comparator Trusts when individuals have a demonstrable track record of high performance against agreed objectives and in their overall contribution to the Trust over a sustained period of time.

In making decisions on executive remuneration the Remuneration Committee will also consider the organisation’s performance, and the individual’s experience, marketability and likelihood of moving elsewhere. Executive remuneration does not currently include provisions for bonus payments linked to the delivery of performance targets. No executive pay should be below the maximum scale for Agenda for Change Band 9.

In March 2015 the Remuneration Committee agreed the median and upper quartile range for each of the executive directors’ pay, and individual directors were placed within that range as per the above pay policy. In addition, it was agreed that the Chief Executive, the Director of Patient Experience and the Director of Finance pay award should be phased in over a two year period, the first portion paid in 2015/16 and the second is due to for implementation in 2016/17 subject to continued good performance.

A recent benchmarking exercise undertaken by the Hay Group suggests that the current salaries paid by the Trust to the Chief Executive and its Executive Directors are generally around the median level paid by Foundation Trusts that are of a similar size to the Trust.

Details on senior manager pay, the future policy table and fair pay multiple are in tables 1-4.


Tabl

e 1

– Se

nior

Man

ager

s (T

he C

hair,

Exe

cuti

ve a

nd N

on-E

xecu

tive

Dir

ecto

rs) R

emun

erat

ion

Curr

ent

Year

End

ing

31 M

arch

201

6Pr

evio

us Y

ear E

ndin

g 31

Mar

ch 2

015

NA

ME

AN

D T

ITLE

Sala

ry a

nd

fees

201

5/16

Ta

xabl

e Be

nefi

ts

2015

/16

(N

ote

11)

Ann

ual

Perf

orm

ance

Re

late

d

Bonu

ses

2015

/16

Long

Ter

m

Perf

orm

ance

Re

late

d

Bonu

ses

2015

/16

Pens

ion

Re

late

d

Bene

fits

20

15/1

6

Tota

l Re

mun

erat

ion

20

15/1

6

Sala

ry a

nd

fees

201

4/15

Ta

xabl

e Be

nefit

s 20

14/1

5

Ann

ual

Perf

orm

ance

Re

late

d Bo

nuse

s 20

14/1

5

(exc

ludi

ng

soci

al s

ecur

ity

cost

s)

Long

Ter

m

Perf

orm

ance

Re

late

d Bo

nuse

s 20

14/1

5

Pens

ion

Rela

ted

Be

nefit

s 20

14/1

5

Tota

l Re

mun

erat

ion

2014

/15

Not

es(b

ands

of

£500

0)(T

o th

e ne

ares

t £1

00)

(ban

ds o

f £5

000)

(ban

ds o

f £5

000)

(ban

ds o

f

£250

0)(b

ands

of

£500

0)(b

ands

of

£500

0)(T

o th

e ne

ares

t £10

0)(b

ands

of

£500

0)(b

ands

of

£500

0)(b

ands

of

£250

0)(b

ands

of

£500

0)

£000

s£s

£000

s£0

00s

£000

s£0

00s

£000

s£s

£000

s£0

00s

£000

s£0

00s

Exec

utiv

e D

irec

tors

Shan

e D

eGar

is,

Chi

ef E

xecu

tive

170

- 17

510

0N

/AN

/A42

.5 -

4521

5 - 2

2016

5-17

00

N/A

N/A

32.5

-35

200-

205

1C

laire

Gor

e, D

irect

or

of P

eopl

e95

- 10

0N

/AN

/AN

/A95

- 10

010

0-10

520

0N

/AN

/AN

/A10

0-10

5

2A

bbas

Kha

koo,

M

edic

al D

irect

or

180

- 185

0N

/AN

/A5

- 7.5

185

- 190

175-

180

0N

/AN

/A0

175-

180

3Tr

evor

May

hew

, In

terim

Fin

ance

D

irect

or

10 -

150

N/A

N/A

2.5-

515

- 20

00

N/A

N/A

N/A

0

Ther

esa

Mur

phy,

D

irect

or o

f the

Pa

tient

Exp

erie

nce

and

Nur

sing

110

- 115

0N

/AN

/A35

- 37

.515

0 - 1

5510

5-11

00

N/A

N/A

40-4

2.5

150-

155

4Te

rry

Robe

rts,

D

irect

or o

f Peo

ple

5 - 1

00

N/A

N/A

N/A

5 - 1

00

0N

/AN

/A0

0

Dav

id S

earle

, D

irect

or o

f St

rate

gy &

Bus

ines

s D

evel

opm

ent

100

- 105

0N

/AN

/A27

.5 -

3014

0 - 1

4595

-100

0N

/AN

/A5-

7.5

105-

110

Joe

Smyt

h, C

hief

O

pera

ting

Off

icer

110

- 115

0N

/AN

/A67

.5 -

7018

0 - 1

855-

100

N/A

N/A

2.5-

510

-15

5Pa

ul W

ratt

en,

Fina

nce

Dire

ctor

110

- 115

0N

/AN

/A17

.5 -

2013

0 - 1

3512

0-12

510

0N

/AN

/A17

.5-2

014

0-14

5


2.2 Cu

rren

t Ye

ar E

ndin

g 31

Mar

ch 2

016

Prev

ious

Yea

r End

ing

31 M

arch

201

5

NA

ME

AN

D T

ITLE

Sala

ry a

nd

fees

201

5/16

Ta

xabl

e Be

nefi

ts

2015

/16

(N

ote

11)

Ann

ual

Perf

orm

ance

Re

late

d

Bonu

ses

2015

/16

Long

Ter

m

Perf

orm

ance

Re

late

d

Bonu

ses

2015

/16

Pens

ion

Re

late

d

Bene

fits

20

15/1

6

Tota

l Re

mun

erat

ion

20

15/1

6

Sala

ry a

nd

fees

201

4/15

Ta

xabl

e Be

nefit

s 20

14/1

5

Ann

ual

Perf

orm

ance

Re

late

d Bo

nuse

s 20

14/1

5

(exc

ludi

ng

soci

al s

ecur

ity

cost

s)

Long

Ter

m

Perf

orm

ance

Re

late

d Bo

nuse

s 20

14/1

5

Pens

ion

Rela

ted

Be

nefit

s 20

14/1

5

Tota

l Re

mun

erat

ion

2014

/15

Not

es(b

ands

of

£500

0)(T

o th

e ne

ares

t £1

00)

(ban

ds o

f £5

000)

(ban

ds o

f £5

000)

(ban

ds o

f

£250

0)(b

ands

of

£500

0)(b

ands

of

£500

0)(T

o th

e ne

ares

t £10

0)(b

ands

of

£500

0)(b

ands

of

£500

0)(b

ands

of

£250

0)(b

ands

of

£500

0)

£000

s£s

£000

s£0

00s

£000

s£0

00s

£000

s£s

£000

s£0

00s

£000

s£0

00s

Non

Exe

cuti

ve D

irec

tors

Rich

ard

Sum

ray,

C

hair

45 -

500

N/A

N/A

N/A

45 -

500

200

N/A

N/A

N/A

0

Kat

ey A

dder

ley,

N

on-E

xecu

tive

Dire

ctor

10 -

150

N/A

N/A

N/A

10 -

1510

-15

N/A

N/A

N/A

N/A

10-1

5

Car

ol B

ode,

Non

-Ex

ecut

ive

Dire

ctor

10 -

150

N/A

N/A

N/A

10 -

1510

-15

N/A

N/A

N/A

N/A

10-1

5

Sora

ya D

hillo

n, N

on-

Exec

utiv

e D

irect

or10

- 15

0N

/AN

/AN

/A10

- 15

0-5

N/A

N/A

N/A

N/A

10-1

5

Prad

ip P

atel

, Non

-Ex

ecut

ive

Dire

ctor

10 -

150

N/A

N/A

N/A

10 -

1510

-15

N/A

N/A

N/A

N/A

5-10

Lis

Paic

e, N

on-

Exec

utiv

e D

irect

or10

- 15

0N

/AN

/AN

/A10

- 15

0-5

N/A

N/A

N/A

N/A

10-1

5

Rich

ard

Whi

ttin

gton

, N

on-E

xecu

tive

Dire

ctor

10 -

150

N/A

N/A

N/A

10 -

150

N/A

N/A

N/A

N/A

0

Not

es o

n Ta

ble

1An

nual

and

Lon

g Te

rm P

erfo

rman

ce R

elat

ed b

onus

es h

ave

not b

een

paid

by t

he Tr

ust a

nd a

re n

ot a

pplic

able.

Pens

ion

Rela

ted

Bene

fits h

ave

been

calcu

late

d us

ing

the

HMRC

met

hod

advis

ed b

y Mon

itor i

n th

e Ann

ual R

epor

ting

Man

ual.

Pens

ion

Rela

ted

bene

fits w

ere

not r

epor

ted

for t

he p

rior y

ear a

s the

figu

res w

ere

not a

vaila

ble.


Tabl

e 2

– Se

nior

Man

ager

s’ P

ensi

on E

ntit

lem

ents

NA

ME

AN

D T

ITLE

Real

incr

ease

in

pens

ion

at a

ge

60 a

t 31

Mar

ch

2016

Real

incr

ease

in

pens

ion

lum

p

sum

at

age

60 a

t 31

Mar

ch 2

016

Tota

l acc

rued

pe

nsio

n at

age

60

at

31 M

arch

20

16

Lum

p Su

m a

t ag

e 60

rel

ated

to

acc

rued

pe

nsio

n at

31

Mar

ch 2

016

Cash

Equ

ival

ent

Tran

sfer

Val

ue

at 1

st A

pril

2015

Real

Incr

ease

in

Cash

Equ

ival

ent

Tran

sfer

Val

ue

Cash

Equ

ival

ent

Tran

sfer

Val

ue

at 3

1 M

arch

20

16

Empl

oyer

’s

cont

ribu

tion

to

sta

keho

lder

pe

nsio

n

Exec

utiv

e D

irec

tors

(Ban

ds o

f £2

500)

(Ban

ds o

f £2

500)

(Ban

ds o

f £5

000)

(Ban

ds o

f £5

000)

£000

s£0

00s

£000

s£0

00s

£000

s£0

00s

£000

s

Shan

e D

eGar

is, C

hief

Exe

cutiv

e 0

- 2.5

0 - 2

.525

- 30

20 -

2529

77

308

N/A

Abb

as K

hako

o, M

edic

al D

irect

or

0 - 2

.52.

5 - 5

45 -

5014

0 - 1

4587

729

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2.2 Table 3 – Fair Pay Multiple

2015/2016 2014/2015

Band of Highest Paid Director’s Total Remuneration (£000) 180 - 185 175 - 180

Median Total Remuneration 30,501 30,206

Ratio 5.98 5.88

Notes on Table 3The HM Treasury Financial Reporting Manual (FReM), requires the Trust to disclose the median remuneration of the Trust staff and the ratio between this and the mid-point of the banded total remuneration of the highest paid director. The calculation is based on full-time equivalent staff of the Trust at 31st March 2016 on an annualised basis. In 2015/16 no employee received remuneration in excess of the highest paid director (2014/15 two employees received remuneration in excess of the highest-paid Director). Remuneration in table 3 excludes pension related benefits in accordance with Monitor instructions. The ratio for 15/16 was 5.98.The ratio for 2014/2015 has been restated as the calculation incorrectly included pension related benefits. This reduced the ratio in 14/15 from 6.70 to 5.88. On this basis, there has been a very marginal increase of 0.1.

Table 4 – Senior Managers earning more than the Prime Minister

2015/2016 2014/2015

(Bands of £5000) (Bands of £5000)

Shane Degaris, Chief Executive 170 - 175 165-170

Abbas Khakoo, Medical Director 180 - 185 175-180

Notes on Table 4The Annual Reporting Manual (ARM) for NHS Foundation Trusts from 2015/16 requires the Trust to disclose all Senior Managers receiving greater remuneration than the Prime Minister (currently £142,500). For the purpose of table 4 Prime Minister comparatives, the average of the banding of Total Remuneration in Table 1 is used. The remuneration in table 4 must be disclosed on a full time, part time, or any other pro rata basis. Furthermore the Trust must disclose what steps it has taken to satisfy itself that the remuneration is reasonable. The process the Trust follows is explained below: The Trust’s exec pay policy is to set executive remuneration between the median and upper quartile of comparator Trusts when individuals have a demonstrable track record of high performance against agreed objectives and in their overall contribution to the Trust over a sustained period of time. In making decisions on executive remuneration the Remuneration Committee will also consider the organisation’s performance, the individual’s experience, marketability, the pay of senior managers on Agenda for Change terms and conditions and the likelihood of them moving elsewhere. Executive remuneration does not currently include provisions for bonus payments linked to the delivery of performance targets. Executive pay was last benchmarked in 2015 by Hay Group who examined data from annual reports and a national survey conducted by the Foundation Trust Network. The Remuneration then considered all executives and the CEO’s salary against the benchmark report and in accordance with the pay policy as set out above. Remuneration in table 4 excludes pension related benefits in accordance with Monitor instructions.

Notes1 Claire Gore left office on 29 February 20162 Clinical work in band of £60 - £65k, Director work in band of £120 -£125k Recharges out to NHS Central London CCG and Imperial College not included in above Included in salary was a Clinical Excellence Award in band of £25k to £30k which was funded by the NHS Commissioning Board CCG.3 Trevor Mayhew commenced office as Interim Finance Director on 16 February 20164 Terry Roberts commenced office as Director of People and Development on 1 March 20165 Paul Wratten left office as Finance Director on 15 February 2016

Other Notes6 Taxable Benefits relate to p11d taxable travel costs paid.

Shane DeGarisChief Executive26th May 2016


2.3Staff report


2.3

reasonable adjustments are made for any candidates who require them, in line with the Trust’s Recruitment and Selection Policy/Resourcing Policy.

Policies applied during the financial year for continuing the employment of, and for arranging appropriate training for, employees who have become disabled persons during the period.

The following policies apply in relation to the above question; Equality & Human Rights PolicyManagers are responsible for ensuring that staff are able to carry out their work in appropriate conditions, including participation in learning and development initiatives and local induction processes. Where necessary, reasonable adjustments must be made to equipment, working or learning arrangements and the physical environment to ensure that disabled staff can carry out their work, and access the full range of learning and development opportunities. These adjustments will be carried out with advice from the occupational health department. In certain circumstances

An analysis of average staff numbers

As at 31 March 2016, the Trust employed over 2,900 staff, of which 75% were female.

We have a growing female workforce which is consistent with the health sector. In 2015/16, female staff represented 75% of our overall workforce with female staff dominating professional groups such as nursing and midwifery (89% female) and allied health professionals. There was an almost equal balance of gender representation within the medical and dental workforce which although historically male has over the last five years seen an increase in female medical doctors to 53%.

Whilst our male workforce is declining, there is stronger gender representation of male staff within admin and clerical and estates and ancillary group.

A breakdown at the end of the year of the number of male and female directors, senior managers, employees

The Trust Board has 13 members, eight male and five female. Women represent 90% of senior managers at band 8 and above. This is above their representation within the workforce and London borough of Hillingdon population.

Sickness absence data

The Trust completed the financial year with a YTD (Year to Date) sickness rate of 3.53% – although this rate is higher than the Trust target of 3%, it was less than the 2015/16 YTD figure of 3.59%. The Corporate Division completed the year with the highest YTD sickness rate (3.78%), followed by W&C (3.68%), Surgery (3.65%),

CCSS (3.64%), and Medicine (3.21%). The estimated YTD cost of sickness to March 2016 was £2,868,697

The overall reduction in the sickness rate for 2015/16 (3.53% compared to 3.59%), can be partly attributed to the focused work carried out by the People Management & Productivity Working Group, (a sub group of the Workforce Transformation Board); which undertook a wholesale review of the managing sickness absence policy, worked with the Divisions to ensure that they captured greater levels of doctors sickness, and delivered sickness absence training to managers as part of the HR Workshops. Further work and initiatives are being planned to help reduce the sickness rate further during 2016/17.

Staff policies and actions applied during the financial year:

Policies applied during the financial year for giving full and fair consideration to applications for employment made by disabled persons, having regard to their particular aptitudes and abilities.

The following policies apply in relation to the above question; Recruitment & Selection Policy, Equality & Human Rights Policy, Employment Checks PolicyThe Trust has a positive approach to disability and subscribes to the “Two Ticks Scheme”. We aim to encourage and support the inclusion of disabled people in accessing the full range of opportunities open to staff, and to promote greater participation in public life.

Managers responsible for conducting any selection or assessment processes are also responsible for ensuring that

There was an almost

equal balance of gender

representation within medical and

dental workforce which although

historically male has over the last five

years seen an increase in female

medical doctors to 53%.


Change Policy are also applied, especially in relation to changes which impact on working arrangements.

Actions taken in the financial year to encourage the involvement of employees in the NHS Foundation Trust’s performance.

The Trust has a culture of engagement and routes through which it involves and listens to its workforce. The senior team is actively involved in welcoming new employees. The CEO uses his monthly briefings to listen to and engage with the workforce. These briefings are held at both the Hillingdon and Mount Vernon sites.

Trust employees contribute to clinical decision making at all levels of the organisation through representation on various committees particularly clinical audit committees. These provide a forum for discussion, problem solving, action planning and review of Trust performance. The Trust has a culture of regular 1:1 meetings between managers and direct reports and their teams. The Performance Development Review meetings provide an additional forum through which staff are involved in decisions about their work, service and performance of the Trust.

are not limited to the following; Raising Concerns at Work Policy, Dignity at Work Policy, Grievance Policy, SpeakInConfidence, escalating concerns to their manager or manager’s manager.

Actions taken in the financial year to consult employees or their representatives on a regular basis so that the views of employees can be taken into account when making decisions which are likely to affect their interests.

The Trust has a number of forums in place to consult with employees or their representatives on a regular basis, so that the views of employees can be taken into account when making decisions which are likely to affect their interests. These forums include; the JNCC (Joint Negotiating Consultative Committee), JLNC (Joint Local Negotiating Committee), Terms & Conditions Committee and subgroups such as the PDR Working Group. The Trust also acts upon information received from the results of the Staff Survey and Staff Friends & Family Test. Other initiatives include the monthly Chief Executive briefing and the Team Brief. Where appropriate the principles of the managing Organisational

the Equality Act 2010 provides that a reasonable adjustment can include treating disabled staff more favourably, such as appointing a disabled member of staff into a role without undergoing a competitive selection process.

Policies applied during the financial year for the training, career development and promotion of disabled employees.

The following policies apply in relation to the above question; Recruitment & Selection Policy, Equality & Human Rights PolicyThe Trust has a positive approach to disability and subscribes to the “Two Ticks Scheme”. We aim to encourage and support the inclusion of disabled people in accessing the full range of opportunities open to staff, and to promote greater participation in public life.

In line with the policies governing recruitment, selection, disability and the Guaranteed Interview Scheme, disabled candidates for any selection process, who meet the essential criteria, will be short-listed for interview. Where appropriate the principles of Positive Action are applied to support the career development and promotion of disabled employees.

Actions taken in the financial year to provide employees systematically with information on matters of concern to them as employees.

The Trust sends out regular bulletins to staff to keep them informed of matters which may be of concern to them. Managers are encouraged to disseminate such information at Team Meetings and/or 1:1 meetings as appropriate. Should employees have concerns which they wish to raise, a number of channels are open to them to do so. These include but


2.3 the Trust receiving high engagement and motivation scores compared with all NHS organisations and acute Trusts. At a local level, most divisions and directorates reported engagement scores above the national average.

We received high ranking scores in areas such as appraisals and staff motivation at work. The survey also indicates that our quality of patient care is improving with a reduction in the number of staff witnessing potentially harmful errors, near misses or incidents. Our staff also reported positive experiences of their work environment seeing us ranking highly in findings relating to health and wellbeing with fewer staff suffering work related stress. The Trust continues to implement measures to improve the working lives of its staff.

Consultancy

The Trust expenditure on consultancy services was £160k. This was for a range of activities including recruitment searches, advice and benchmarking.

Off payroll engagements

See appendix B.

Exit packages

There were three non-compulsory packages at a total value of £10k.

Reporting of high paid off-payroll arrangements

See appendix B.

(Sharps Instruments in Healthcare) Regulations 2013 in a timely manner. To meet the regulations fully the Trust substituted all traditional unprotected medical sharps with a ‘safer sharp’ where it was practicable to do so by 29 May 2015.

Health and safety governance: The Health and Safety Committee has met quarterly and the Board has received quarterly reports on health and safety issues and performance throughout the year.

Training: All new members of staff receive health and safety training during their corporate induction. Fire safety training has been completely reviewed and as a result, attendance has increased.

Performance: During this reporting period there were a total of 1,315 incidents reported, indicating a downward trajectory.

Information on policies and procedures with respect to countering fraud and corruption.

The Trust has a Counter Fraud Policy in place which highlights to staff what they should do in the event that they suspect fraud or corruption. The Trust also has in place a Raising Concerns at Work Policy (Whistleblowing), and an anonymous dialogue system called “SpeakInConfidence”, which can also be used for the purposes of raising concerns.

Staff survey results

The Trust received a positive staff survey with a majority of the survey’s key findings reporting improvements in performance and placing the Trust in the top 20% of acute trusts.

Historically the Trust has a well engaged workforce and the 2015 survey findings were no exception with

Staff are encouraged through our Bright Ideas scheme to submit ideas and activities for improving the quality of the workplace and patient care. This is actively promoted through email and via the Trust bulletin.

In addition, staff governors play a part as members of the Council of Governors and will bring matters forward from staff to governors’ meetings.

We continue to use the findings from the annual staff survey report to engage our staff. With the involvement of staff and teams, action plans are developed from its findings and taken forward for the benefit of staff and patients.

The Trust has a culture of partnership working with its staff and staff side colleagues. This relationship is supported via three main forums through which staff are consulted in decisions about the organisation.

The Trust has an Occupational Health Department which provides information and support to staff. In addition the Trust has an Employee Assistance Program in place, which is open to all Trust employees – details are published in the Trust Intranet page. Occupational Health and Managers will refer staff to the service as appropriate. The Trust also promotes Occupational Health services at internal health promotion events and the Trust’s New Joiners Event.

Health and safety

Through its Health and Safety Strategy the Trust continues to work towards best practice standards of health and safety for all our staff in the workplace, for members of the public, patients, and others who enter our premises.

In February 2015 the Trust was issued with an improvement notice for failing to implement the Health and Safety


Appendix A – Breakdown Workforce by Gender

Total Female Male

Medical and Dental 412 53% 47%

Nursing and Midwifery Registered 865 89% 11%

Allied Health Professionals 159 79% 21%

Female % Male %

Add Prof Scientific and Technic 55 3% 25 3%

Additional Clinical Services 383 17% 73 10%

Administrative and Clerical 473 21% 141 19%

Allied Health Professionals 125 6% 34 5%

Estates and Ancillary 147 7% 171 23%

Healthcare Scientists 42 2% 16 2%

Medical and Dental 216 10% 196 26%

Nursing and Midwifery Registered 769 35% 96 13%

Students 6 0% 0.6 (part time) 0%

Staff Group Summary Total 2,218 752

Appendix B

Table 4B: For all off-payroll engagements as of 31 Mar 2016, for more than £220 per day and that last for longer than six months

8A1 Maincode

2015/16

Number of engagements

Number Subcode

No. of existing engagements as of 31 Mar 2016 16 100

Of which:

Number that have existed for less than one year at the time of reporting 7 110

Number that have existed for between one and two years at the time of reporting

4 120

Number that have existed for between two and three years at the time of reporting

0 130

Number that have existed for between three and four years at the time of reporting

1 140

Number that have existed for four or more years at the time of reporting 4 150

Confirmation:

Please confirm that all existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought.

Yes 160


Table 4C: For all new off-payroll engagements, or those that reached six months in duration, between 01 Apr 2015 and 31 Mar 2016, for more than £220 per day and that last for longer than six months

8A2 Maincode

2015/16


Number Subcode

Number of new engagements, or those that reached six months in duration between 01 Apr 2015 and 31 Mar 2016

7 100

Number of the above which include contractual clauses giving the trust the right to request assurance in relation to income tax and national insurance obligations

4 110

Number for whom assurance has been requested 0 120

Of which:

Number for whom assurance has been received 0 130

Number for whom assurance has not been received* 0 140

Number that have been terminated as a result of assurance not being received

0 150

Table 4D: For any off-payroll engagements of Board members, and/or senior officials with significant financial responsibility, between 1 Apr 2015 and 31 Mar 2016

8A3 Maincode Expected

2015/16


Number Subcode Sign Checks

Number of off-payroll engagements of Board members, and/or, senior officials with significant financial responsibility, during the financial year.

0 100 + Pass

Number of individuals that have been deemed “Board members and/or senior officials with significant financial responsibility”. This figure should include both off-payroll and on-payroll engagements.

16 110 + Pass

In any cases where individuals are included within the first row of this table, please set out:

Checks

Details of the exceptional circumstances that led to each of these engagements.

Pass

Details of the length of time each of these exceptional engagements lasted. Pass

In any cases where, exceptionally:- the Trust has engaged without including contractual clauses allowing the Trust to seek assurance as to their tax obligations; or- where assurance has been requested and not received, without a contract termination please specify the reasons for this.

In three cases the Trust has made engagements without including clauses allowing the Trust to seek assurance as to their tax obligations. These are staff that have been engaged at relatively short notice due to very pressing operational service needs and to deal with waiting list issues. Where relevant, the Trust is still in the process of putting contracts in place with the required clauses and of seeking the required assurances.


2.4Compliance with NHS Foundation Trust Code of Governance


2.4

Following review, the Board has identified that the Trust is currently non-compliant with the following provisions of the updated Code.

Provision A.1.1: The Trust is not compliant with this provision in that the procedure for how conflicts between the Board and Council of Governors are addressed, is contained in a separate document that covers engagement between the Board and Council of Governors. These arrangements are consistent with the principles of the Code in that a clear written conflict resolution process is in place and regularly reviewed. The Trust will be reviewing its constitution in 2016/17 and this process will be incorporated into the constitution.

The Hillingdon Hospitals NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in 2012.


2.5Regulatory ratings


2.5 Monitor, the independent regulator, assigns Foundation Trusts two risk ratings each quarter. These risk ratings cover finance risk and governance risk. During quarter 2 of 2015/16, Monitor introduced the Financial Sustainability Risk Rating which replaced the Continuity of Services Risk Rating for assessing finance risk.

The continuity of services risk rating identified the level of risk to the ongoing availability of key services. The continuity of services risk rating incorporated two measures of financial robustness:

a) liquidity: days of operating costs held in cash or cash-equivalent forms, including wholly committed lines of credit available for drawdown; and

b) capital servicing capacity: the degree to which the organisation’s generated income covers its financing obligations.

The Financial Sustainability Risk Rating incorporates liquidity and capital service capacity but also adds two further measures. These are:

c) income and expenditure (I&E) margin: the degree to which the organisation is operating at a surplus/deficit

d) variance from plan in relation to I&E margin: variance between a Foundation Trust’s planned I&E margin in its annual forward plan and its actual I&E margin within the year.

As before, the governance risk rating continues to be generated by Monitor considering a range of information about an FT. This information covers the following areas:

> Performance against national access and outcomes requirements

> Care Quality Commission judgements

> Third party information

> Quality governance indicators

> Continuity of services and aspects of financial governance.

Monitor can also consider any other relevant information when calculating the governance risk rating.

Where there are no grounds for concern at a Trust, Monitor will assign a green rating. Where Monitor has identified a concern at a Trust but not yet taken action, it will provide a written description stating the issue at hand and the action it is considering. A red rating will be assigned when Monitor has begun enforcement action.

The governance rating in 2015/16 remained ‘under review’ as it had been since Q3 of 2014/15 following the CQC inspection of the Trust. Monitor advised that the risk rating would remain ‘under review’ until the CQC had concluded a follow-up inspection of the warning notices that had been issued.

A full quarter by quarter breakdown of the Trust’s financial risk ratings in 2014/15 and 2015/16 is presented below.

There have been no formal interventions by Monitor at the Trust.

2015/16 Annual Plan Q1 Q2 Q3 Q43

Continuity of Service rating 2 2

Financial Sustainability rating 2 2 2

Governance rating ‘Under review’‘Underreview’ ‘Under review’ ‘Under review’

2014/15 Annual Plan Q1 Q2 Q3 Q4

Continuity of service rating 3 3 3 3 3

Governance rating Green Green Green ‘Under review’‘Underreview’

3. The Q4 risk ratings are based on the Trust’s submission to Monitor at the end of April 2016: the Trust does not have Monitor’s confirmed Q4 ratings at the time of finalisation of the report (May 2016).


2.6Statement of the Chief Executive’s Responsibilities as the Accounting Officer


2.6The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by Monitor.

Under the NHS Act 2006, Monitor has directed The Hillingdon Hospitals 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 The Hillingdon Hospitals 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;

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

> Prepare the financial statements on a going concern basis.

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

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor’s NHS Foundation Trust Accounting Officer Memorandum.



2.7Annual Governance Statement 2015/16


2.7Directors are professionally accountable to the Medical Director. The Director of Patient Experience and Nursing provides professional accountability and support to the Assistant Directors of Nursing.

Risk management and awareness training is mandatory for all Trust employees and is included in the ‘New Employees Week’ programme. The Trust’s Health and Safety team deliver risk management training appropriate to all levels across the Trust including the Trust Board. The Nursing Education Skills Programme is reviewed three monthly, and updated to ensure that the latest evidence-based/best practice is incorporated.

4. Risk control framework

4.1 Risk Management Strategy

The Trust Board approved the Risk Management Strategy and Policy (including Board Assurance Framework) at its meeting on 29th April 2015. This strategy ensures that the Trust approaches the control of risk in a strategic and organised manner and sets out the responsibilities of Executive Directors and Senior Managers in relation to risk management and makes it clear that all employees have a role to play in risk management appropriate to their level.

The Audit & Risk Committee (ARC) provides assurance that there is a sound system of internal control and governance, ensuring that risks to the delivery of the Trust’s services are identified and addressed. Corporate

internal control including systems and resources for managing all types of risk. The Trust Board approved Risk Management Strategy and Policy (including Board Assurance Framework) ensures that the Trust approaches the control of risk in a strategic and organised manner. It sets out the responsibilities of Executive Directors and Senior Managers in relation to their leadership in risk management and makes it clear that all employees have a role to play in risk management appropriate to their level. The Board reviewed its committee structure to provide assurance and challenge the Trust’s risk management process in October 2015 and refocused the Audit and Assurance Committee to be an Audit and Risk Committee to provide improved focus on risk management and a Quality and Safety Committee to provide improved focus on clinical quality and patient safety. A new Board Committee was put in place to focus on capital investment and our estate. Each of these committees are chaired by a Non-Executive Director to enhance this challenge, and the Chair’s report formally to the Board to escalate issues that require further Board discussion.

Following a fundamental review of how governance and clinical quality could be placed at the heart of our culture, the Trust moved to a new clinically led organisation with the appointment of four Divisional Directors in April 2015. The Divisional Directors, (who are Medical Consultants) are accountable to the Chief Operating Officer and responsible for the safe and efficient management of the clinical divisions within the Trust. Each Divisional Team comprises of a Divisional Director, who line manages Assistant Directors of Operations and Assistant Directors of Nursing. The teams work together to provide robust management and high quality and efficient care. Divisional

1. Scope of responsibility

As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum.

2. The purpose of the system of internal control

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of The Hillingdon Hospitals NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in The Hillingdon Hospitals NHS Foundation Trust for the year ended 31 March 2016 and up to the date of approval of the annual report and accounts.

3. Capacity to handle risk

The Board is responsible for reviewing the effectiveness of the system of


> A detailed quarterly overview of complaints in terms of themes, lessons learned and actions taken; claims and litigation data; incidents numbers, severity and themes by clinical division and corporate level clinical risk and actions being taken to address is also received at CGC with performance exception reporting at QSC.

> Clinical divisions review their quality data in relation to patient safety, patient experience and clinical effectiveness on a monthly basis at their Divisional Governance Boards; a divisional exception report is received by the CGC and any concerns on quality are escalated via this Committee to the QSC.

> The Board has developed a structured process of reporting the investigation of Serious Incidents and the follow up of outcomes and action plans resulting from Serious Incidents (SIs). SIs have a named Executive lead and panel reports are presented to the Board with resulting actions reviewed bi-monthly until complete. Root Cause Analysis (RCA) is used and forms the basis of the report together with the creation of action plans. Serious Incidents occurring in the 2015/16 year are discussed on page 31 of the Quality Report.

> There is a programme of regular inspections of clinical areas by the Director of Nursing and Patient Safety, Chief Executive and other Board members giving them the opportunity to talk to staff and patients about their experience. In addition, re-vamped Patient Safety walk-arounds, involving Board members, are to be introduced during 2016/17.

> ‘Clinical Fridays’ allow the corporate nursing team and divisional senior

> Target risk levels, including the date by which this should be attained and frequency of risk review agreed.

4.2 Quality Governance Arrangements

The key quality governance and leadership structures, that support the Trust in ensuring that the quality of care is being routinely monitored across all services and that poor performance or variation in quality is challenged, are as follows:

> There is monthly reporting to the Board via the integrated quality and performance report with exception narrative.

> At each Quality and Safety Committee (QSC) meeting a clinical division presents on clinical and quality governance issues, discusses areas of risk, reviews performance against key quality indicators and progress of work in relation to learning from clinical incidents and clinical audit.

> There is now a deep dive review at each QSC meeting on the key aims of a new Quality Improvement Strategy. Any external quality and safety intelligence is presented at the QSC on a bi-monthly basis, and a summary of performance against KPIs in the Annual Quality Report “Look forward” section are also reported with escalation to the Board where required.

> The Trust has a Clinical Governance Committee (CGC) which receives bi-monthly reports from each clinical division outlining areas of risk, progress against national audit requirements, reviews key patient safety indicators, clinical effectiveness and patient experience data.

risks are reported from ward to Board via Divisional Governance Boards and using the online risk register managed by the Trust’s Governance department.

The Board Assurance Framework (BAF) is a key proactive risk identification tool for the Trust. The Trust’s strategic objectives are reviewed annually, and mapped into the BAF. The BAF provides the Board with assurance that significant threats to achieving Trust objectives have been identified and are being appropriately controlled. Actions within the BAF address how assurances will be provided; or, where assurances have identified inadequate controls, how controls will be improved. The BAF also cross references to the corporate risk register and to regulatory standards e.g. CQC, that the Trust needs to comply with.

In 2015/16 The Trust commissioned an internal audit of the BAF to ensure that it effectively identifies risk and provides effective risk management control. The outcome of the internal audit was received in April 2016 and provided reasonable assurance. The Trust has reviewed the recommendations and prepared a management action plan to further strengthen the BAF in 2016/17. The ARC reviews the BAF at its quarterly meetings. The Trust Board reviews the BAF twice a year and there is an annual Board Seminar to refresh the BAF.

Risk appetite, as well as risk tolerance, is addressed in the Risk Management Strategy & Policy. At the Board Seminar in March 2015, which reviewed the Risk Management Strategy & Policy, amendments were made to risk appetite and risk tolerance strengthened. These changes are summarised:

> Adoption of the NPSA (National Patient Safety Agency) risk evaluation matrix


2.7 > The Learning from Mistakes league table recently published by Monitor and the Trust Development Authority has ranked the Trust as ‘good’ for levels of openness and transparency based on assessment of key criteria from the Staff Survey Data 2015 and NRLS reporting.

4.3 Quality of Performance Information

The Trust’s Data Quality Steering group reports into the Audit and Risk Committee on a quarterly basis to provide assurance on accuracy of information provided to the Board. In addition, the divisional data quality groups and elective performance meetings review data quality risks on a monthly basis and report to the steering group on progress and actions to address them. Through these groups risks are actively reviewed and addressed through the data quality framework that has been established. The qualified opinion on the Quality Report from the auditor, Deloitte LLP is explained in Part 3 of the Quality Report.

4.4 Care Quality Commission (CQC) Compliance

The Trust was inspected by the CQC in October 2014, and received its final rating in February 2015. The CQC rated the Trust overall as ‘Requires Improvement’ (with inadequate for ‘safe’; requires improvement for ‘effective’, ‘responsive’ and ‘well-led’; and a good rating for ‘caring’). Two Warning Notices were received on Regulation 12: “Cleanliness and Infection Control” and Regulation 10: “Assessing and Monitoring the Quality of Service Provision”.

the Trust as a learning organisation which is always striving for quality improvement. Patients can complete local patient experience surveys, including the Friends and Family Test, provide feedback via NHS Choices, in person directly to department managers and matrons or via the PALS/Complaints offices. There is opportunity for patients and members of the public to attend the Trust’s People in Partnership (PiP) meetings, Council of Governors meetings and the Trust Board meeting. There are also specialty-based focus and support groups where patient feedback can be obtained. The Board receives patient stories as part of understanding the patient experience; this ensures that the voice of the patient and their families/carers is heard first hand by Board members; stories are captured directly from patients via 1:1 interviews, complaints and PALS feedback.

nurses, alongside the DPEN, to work with clinical staff on wards and in departments to experience the environment and delivery of care, engaging with staff and patients and their carers. Any issues or concerns are escalated accordingly to the Executive Team and Trust Board. There is a robust framework to ensure that all service changes have a Quality Impact Assessment (QIA) which is then reviewed by the Medical Director. Any schemes where there are quality concerns are reviewed at a multi-professional Clinical Assurance Panel (CAP), with the project leads presenting the scheme and the actions being taken to mitigate any associated risks to quality.

> Listening to patients/governors: it is important that there is a range of opportunities to support patients in providing feedback and raising their concerns. This is welcomed by


4.6 The organisation’s major risks

Clinical risks 2015/16:

> Suboptimal staffing issues in relation to potential risk of inadequate nursing levels due to a combination of vacancies, due to national shortages and additional capacity being opened to meet surge in demand. This risk is mitigated in real-time by proactive review of staffing by senior nurses and midwives to ensure each area is staffed in line with actual need. Average shift-fills rates are also reviewed retrospectively alongside patient-centred outcome indicators. There has, and continues to be, ongoing and frequent recruitment, with each divisional team working in partnership with the recruitment manager to progress plans specific to the needs of their specialities.

> Failure to meet hospital acquired infection targets: Clostridium difficile infection (CDI). In 2015/16 the Trust exceeded the trajectory of eight with a total of 12 cases. Mitigations included: Delivery of the Infection Prevention & Control annual action plan and continuing to embed the ‘Start Smart, Then Focus’ antimicrobial prescribing guidance. Each Trust attributed CDI case, through the Root Cause Analysis (RCA) process, was assessed with actions generated by this process being implemented in a timely way. Only one case was deemed a ‘Lapse in Care’ as agreed with our commissioners; the other eleven cases were deemed to have been treated appropriately and there was no evidence of cross infection or inappropriate infection control practice. Infection control rates are reviewed by the Infection Control Committee, QSC and the Board.

Commissioning Group. The Trust aspires to be rated as ‘good’ or above in future inspections.

4.5 Data Security

The Trust has had no data cyber-security/information governance incidents categorised at level 2 in 2015/16, therefore is not subject to any investigations by the Information Commissioners Office.

Low scoring minor incidents are reported and monitored at the Information Governance Steering Group which meets a minimum of four times a year and is chaired by the Trust’s Senior Information Risk Owner.

A targeted re-inspection, in May 2015, resulted in the lifting of the two warning notices and an improved rating for patient safety. However, a requirement notice, against regulation 12; “safe care and treatment”, specifically focused on infection and prevention and control, was applied.

During 2015/16 an intensive improvement programme, driven by Executive leads, strengthened governance and assurance arrangements. This included Executive-led CQC Sit-rep meetings, monthly updates to the Trust Management Executive and Trust Board and the Clinical Quality Group (CQG) arm of the Clinical


2.7need to staff escalation beds. Due to the mitigations put in place by management during the year the Trust reduced its deficit of £1.5m.

> The scale of investment required to improve the Trust’s fragile estate infrastructure exceeds the Trust’s financial capacity. Remedial work and repairs have been assessed at £67m. Failure to maintain the estate comes under Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: Safety and Suitability of Premises. The condition of key building systems is assessed by a 5 yearly survey, and is risk assessed and rated against available capital. However the currently available funds are insufficient to meet the need. This funding shortfall has been raised with both Monitor and the Department of Health.

The main future risks facing the Trust are summarised:

Future clinical risks:

> The Trust may fail to achieve 95% A&E target leading to a breach of the Monitor Licence: The Trust is working with Hillingdon Clinical Commissioning Group, Hillingdon Borough Council, Hillingdon Community Health and the third sector (voluntary sector) to integrate care and ensure that admissions to hospital are avoided where possible; and, that time spent in the A&E department is reduced. Action will be taken, following a recent independent review of patient flows, to and through the A&E department

of the ‘Junior Doctors’ training programme.

The following clinical risks were also managed in 2015/16 and mitigating actions continue into 2016/17:

> The Trust Provision of 24/7 Interventional radiology service

> High dependency care for children

> Escalation of deteriorating patients

> Medicine security and storage.

Each of the risks described above has a detailed mitigation plan, with actions and timescales in place to achieve a level of risk that the Trust considered manageable for that risk.

Finance risks in 2015/16:

> Under delivery of planned savings from the Quality Innovation Productivity and Prevention (QIPP) due to increased demand for services and unplanned costs relating to CQC compliance. This risk is mitigated by robust project planning supported by a rigorous monthly and quarterly performance management framework, monthly formal QIPP reviews and monthly Trust Board reporting.

> The under delivery of QIPP savings had a consequential effect on our liquidity. The Trust has a committed working capital facility with the Independent Trust Financing Facility (ITFF) and an agreed contract with Hillingdon Clinical Commissioning Group (CCG) that reduces the risk of cash flow problems. The risk of healthcare revenue falling and leaving the Trust with a deficit in-year was in part mitigated by an agreed contract based on a guaranteed minimum financial value, with an agreed marginal rate for over performance with additional support agreed in-year due to the on-going

> Through an inability to meet the clinical standards, deliver the requisite workforce, deliver behavioural change, sustain expected patient experience and an unsustainable demand on the system, Shaping a Healthier Future (SaHF) does not deliver the planned benefits to improve quality and safety of health and care across NW London. Clinical standards were approved in the Decision Making Business Case and all providers are now creating plans which support the delivery of these standards – this will remain under review by the Clinical Board.

> CT scanner at Hillingdon Hospital: This risk was mitigated via the acquisition of a Spec CT Scanner which will allow a degree of cover for the main CT scanner when service or repair is required and also allow us an increase in productivity. Vacancies within the senior management pathology structure: This risk was mitigated through the use of interim cover during the recruitment process. All vacant posts have now been filled substantively.

> Care of psychiatric patients in A&E: This risk was controlled to a reasonable level by implementation of more robust processes for monitoring and risk assessing patients with mental health issues presenting to A&E.

> Number and experience of paediatric staff in A&E: This risk was controlled to a reasonable level through the recruitment of additional specialist medical and nursing posts and via the implementation of a competency framework assessment process for newly recruited nursing staff as well as incorporating paediatric specialist training sessions provided by consultant paediatricians as part


initiation document that requires risk assessment. Any significant risks identified need a comprehensive Quality Impact Assessment (QIA) that is reviewed by the Clinical Assurance Panel (CAP) led by the Medical Director. The CAP reviews, approves or rejects any schemes, thereby assuring the organisation that change and transformation programmes do not pose a material risk to the delivery of safe, high quality care. The CAP also reviews quality KPIs related to projects to track any changes alongside key changes to service delivery.

> Increasing cost of compliance to meet statutory and regulatory service and infrastructure standards particularly in light of the recent CQC report and the need for major investment in staff and the estate. This risk is being addressed by management with a phased approach to both revenue and capital investment over the next two financial years. The Medical Director, Nurse Director and Chief Operating Officer have together reviewed the required investment and prioritised first expenditure to rectify and sustain warning notice and must-do compliance issues. The financial consequences of this process have been built into the Trust’s 2016/17 annual financial planning.

> Cash required for day to day operations and for investment could fall short of what is required and start to impede on service delivery. To manage this risk in addition to the £4.1 million cash balance at the start of the year and £6.0 million of assessed working capital headroom available, management have the ability to access £6m of working capital facility. In addition, a routine monthly payment has been agreed with East and North Hertfordshire Hospitals NHS Trust for services received on

financial risk sharing to redesign clinical pathways, yet at the same time provide sufficient revenue to cover the Trust’s costs; including guaranteed minimum financial values that can be enhanced and/or fixed cost transitional support.

> Commissioning risk if the cost of activity is not paid for in full. The form of healthcare contract the Trust will agree with its lead commissioner will guarantee a minimum payment with an agreed rate of over performance. However, as was the case in 2015/16 the minimum value can be enhanced by negotiation to cover justifiable excess costs of delivering service levels above the agreed contract. Monthly formal contract meetings with Hillingdon CCG as lead commissioner are in place so financial and service issues can be flagged and addressed quickly as necessary.

> Recruitment to fill vacancy levels is insufficient to enable the Trust to significantly reduce its agency costs. This is being addressed by a focused recruitment and retention programme including overseas initiatives and is subject to continual management review.

> The level of savings required in 2016/17 has an adverse impact on the quality of care provided. To give the Trust the very best opportunity of delivering its savings, a Project Management Office (PMO) is in place to support managers and clinicians to achieve identified savings plans. Throughout the year weekly/fortnightly risk assessment allows early signs of potential areas of non-delivery to be identified and ensure mitigating actions are put in place to prevent slippage or non-delivery. To manage the service risk as robustly as possible all savings schemes have a project

and into the Acute Medical Unit, to improve patients’ waits in A&E.

> We fail to deliver high quality patient care as a result of inadequate staffing provision and in line with the 7-day workforce initiative: The Trust is reviewing its clinical and support service workforce using acuity and dependency tools and other mechanisms; to improve frontline clinical staff numbers and care at the bedside seven days a week. The Trust will continue to drive forward a robust recruitment and retention work programme to reduce the number of vacancies and to support the increased activity that the Trust has seen during this past year.

> We fail to meet compliance with the expected standards set out by our regulators – this could impact on the Trust achieving a ‘good’ rating with the CQC. The Trust continues to strengthen its governance arrangements and its compliance with the Health and Social Care Act regulations through a programme of internal peer reviews and mock inspections to ensure there is evidence of improvement against a refreshed CQC action plan for 2016/17. There will be increased scrutiny of operational performance and quality data and a new accountability framework to ensure compliance with policy and delivery of statutory targets. Particular attention will be devoted to areas of outstanding compliance notices, most notable of which is infection control.

Future financial risks:

> Commissioning risk that Hillingdon CCG’s out of hospital strategy results in Trust deficit. This will be mitigated by continuing to agree contracts with Hillingdon CCG that promote robust collaborative working and


2.7NHS Foundation Trust condition 4 (FT Governance) is reviewed at least every six months. In October 2015 and April 2016 the ARC received an assurance report that risks, identified by the Executive team, relating to the delivery of the Annual Monitor Corporate Governance Board Statements are being managed appropriately. All statements were ‘confirmed’.

These assurances were then re-reviewed by the Executive Team prior to their presentation at the May 2016 ARC; ahead of the Trust Board review to ‘confirm’ or ‘not-confirm’ the Corporate Governance Statement.

There have been some Internal Audit reports reviewed by ARC giving ‘limited assurance’ this year. In most cases actions have been taken to close down the gaps; however further diligence is required to drive them to timely completion. Outstanding issues reside

in a modern form, but this may require capital beyond the capacity of the Trust.

> Public access to services and car parking. Local Council Planning approval has been granted to enable a modest increase in the number of car parking spaces available which will relieve the current pressure with other initiatives being explored to reduce demand.

Overall, the Trust will remain focused on the tension between quality, safety, financial efficiency, and risk to ensure that patient care remains uncompromised. The Trust will do this by having regular Board and Executive reviews of progress and delivery of agreed plans and check that all schemes are quality impact assessed.

4.7 Compliance and Validity of the NHS Foundation Trust condition 4 (FT Governance): Corporate Governance Statement

The Trust has a system in place to ensure that compliance with the

the Mount Vernon site thereby increasing monthly cash flow.

Future Estate Risk:

> The estate has suffered from under-investment over an extended period and many building services have failed or are beyond their economic and design life cycle. There is a risk that the Trust is unable to access sufficient funding to sustain safe services in the short to long term. Key facilities such as theatres, Critical Care and many wards are of a design and condition that does not lend itself to the delivery of modern high quality healthcare. A waste incinerator that provides the majority of heat to the Hillingdon acute site has a remaining operational life of only 2-3 years. Investment in energy efficiency has been very low and a major replacement energy centre will be needed. Most of the engineering plant is of 1960s vintage, and some has fallen into disuse while others are increasingly prone to failure. The optimum long-term solution is likely to entail re-providing core facilities


and the Trust Development Authority has ranked the Trust as ‘good’ for levels of openness and transparency based on assessment of key criteria from the Staff Survey Data 2015 and NRLS reporting.

4.11 Registration with CQC

The Trust is fully registered with the CQC. The Trust has been issued with its certificate for 2015/16: Reference number: RGP1-2229469163.

4.12 Pension Scheme

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.

4.13 Assessing our Impact on the Environment

The Hillingdon Hospitals NHS 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. Adaptation reporting uses a risk assessment approach; coupled with regular detailed buildings condition survey, in conjunction with resilience planning, based on weather-based risks e.g. heat wave, extreme cold, drought, and flood.

> Engagement with the local Health Overview and Scrutiny Committee

> Engagement with the Local Healthwatch

> The Council of Governors is consulted on key issues and risks as part of the annual plan

> Regular People in Partnership Forums enables the Trust to listen to the views and opinions of the communities we serve, share information about what the Trust is doing, and planned future developments, and provides an opportunity for members to meet and communicate with staff, Governors and fellow members

> Annual Members Meeting

> Engagement with user and support groups e.g. Fighting Infection Together, Maternity Services Liaison Committee, People Improving Cancer Services and the Patient-led Assessment of the Care Environment (PLACE)

> Inviting public members and local stakeholders to identify priorities for our Quality Report.

4.10 Incident Reporting

There are structured processes in place for incident reporting, the investigation of Serious Incidents and following up outcomes from Board commissioned external reports. The Trust Board, through the Risk Management Strategy & Policy (including BAF) and the Incident Policy (including Serious Incident (SI), promotes open and honest reporting of incidents, risks and hazards. The Trust has a positive culture of reporting incidents enhanced by accessible online reporting systems available across the Trust. The latest available National Reporting Learning System (NRLS) report (covering 1 April 2015 – 30 September 2015) has shown the Trust to be in the middle 50th percentile for incident reporting. The Learning from Mistakes league table recently published by Monitor

with some internal audit actions and these are followed up by Internal Audit and reported accordingly to ARC.

The Trust believes that effective systems and processes are in place to maintain and monitor the following:

> The effectiveness of governance structures

> The responsibilities of Directors and sub-committees

> Reporting lines and accountabilities between the Board, its sub-committees and the executive team

> The submission of timely and accurate information to assess risks to compliance with the Trust’s licence

> The degree and rigour of oversight the Board has over the Trust’s performance.

4.8 Equality, Diversity and Human Rights

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. Equality impact analysis/assessments are carried out as standard procedure for all Trust policies and new developments/service changes. An equality and diversity toolkit is available for staff on the Trust’s intranet to support them with completing an EIA. The Trust has an Equality and Diversity Steering Group and an annual report is presented to the Trust Board. The Trust has published its statutory equality & diversity report providing assurance that the Trust is compliant with equality legislation.

4.9 Engagement with Stakeholders

The Trust works with its key public stakeholders to manage its risks. This is done through the following mechanisms:


2.7coverage of work for each Board committee is also included in this section of the annual report.

6. Information Governance

The Trust has an established Information Security Management System (ISMS) similar to that defined within the International Standard (ISO) 27001. This entails the identification and classification of information assets, risk assessing those assets and then establishing control frameworks to keep those assets secure. The Trust is committed to establishing ISMS through its compliance with the Information Governance (IG) Toolkit.

The Information Governance Strategy sets out the arrangements for governing information risk, i.e. the framework of accountability and the roles and the responsibilities of staff, management and committees. Together these help the organisation meet its legislative and regulatory requirements, including the requirements from the Health and Social Care Information Centre (HSCIC) for organisations to manage the security of their information. Compliance evidence for Version 13 of the IG Toolkit has been uploaded to HSCIC and all requirements are at a level 2 or 3. Additionally, Internal Audit re-audited the IG toolkit in February 2016 and gave reasonable assurance.

The ICT department has effective policies, procedures and processes in place to ensure that the information processed by information assets and users are kept secure and confidential.

of bad debts and contingent liabilities. The value of losses and special payments has reduced this year and remain immaterial at less than 0.2% of the Trust’s turnover.

The Trust has a Transformation Committee that meets quarterly to review the Trust’s transformation programme and major strategic service change business cases. This includes the use of information technology to lever change. Value for money discussions take place at a management group chaired by the Chief Operating Officer where the discussion is based on service line reporting reviewing how much a service costs to run versus the income it generates and how it is performing both clinically and operationally.

Further information with reference to the Trust’s financial future regarding the Going Concern assessment, is included in the Performance Report of this Annual Report.

There are a range of internal and external audits that provide further assurance on the quality of financial data, economy, efficiency and effectiveness, these include internal audit reports on creditors, financial reporting and budgetary control, healthcare contracting & payment by results, cash management, cost improvement programmes, and financial and activity data and clinical coding. These are all reported to ARC.

5.1 Compliance with the Code of Governance

The Board has reviewed itself against the NHS Foundation Code of Governance. The Board has made the disclosures required by the Code in the governance section of the Directors’ Report, including explanations for non-compliance with provisions of the Code. Attendance records and

5. Review of economy, efficiency and effectiveness of the use of resources

The following key processes are in place to ensure that resources are used economically, efficiently and effectively:

> Scheme of Delegation and Reservation of Powers approved by the Board sets out the decisions, authorities and duties delegated to officers of the Trust

> Standing Financial Instructions detail the financial responsibilities, policies and procedures adopted by the Trust. They are designed to ensure that an organisation’s financial transactions are carried out in accordance with the law and Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness

> Robust competitive processes are used for procuring non-staff expenditure items. Above £25k, procurement involves competitive tendering

> All procurement tendering activities are published within nominated publications and in line with Public Contracts Regulations 2015

> Saving schemes are assessed for their impact on quality with local clinical ownership and accountability

> Use of National and London benchmarking for non-clinical support functions

> Use of Lord Carter review and Model Hospital Information for Clinical specialties and support services.

The Trust Board has gained assurance from the ARC that financial and budgetary management is robust across the organisation. The ARC also receives quarterly reports regarding losses, special payments and compensations (with high value – over £50k approved by the Board), write-off


2.7who collect and maintain an overview of quality information. Alongside key quality indicators as part of the integrated quality and performance report, information is also included on clinical audit, clinical incidents, SIs and the learning from them, complaints and claims. This flow of information ensures that key risks to quality are identified.

The findings of the CQC inspection conducted in October 2014 raised concern over existing processes and systems that maintain patient safety and ensure the delivery of quality care – this included the robustness and critical scrutiny of the corporate risk register by senior management and the tolerance of poor performance against local and national standards and targets. The Trust has a robust improvement plan since this inspection, outlined previously in this report, as recognised by the CQC on its re-inspection of the Trust in May 2015. The Trust can now demonstrate a more effective and robust implementation of policy and procedure to ensure risks to patient safety are reduced alongside achieving positive outcomes for patients.

The Trust has a comprehensive clinical audit work plan covering both national and local audits. Regular updates on clinical audit are reported to the CGC on a quarterly basis with exception reporting to the QSC. Progress against national and local audits and actions being taken are detailed in the Quality Report to ensure transparency on our performance against these.

process. Having the right structures and processes in place allied to an appropriate culture with supporting values and behaviours is strongly emphasised. In 2016/17 the Trust will be launching a new Quality and Safety Improvement Strategy which will drive the governance and leadership on quality improvement over the next three years.

The 2015/16 Quality Report4 provides evidence of progress and priorities for improvement and is aligned with our clinical quality strategy objectives and our overall Trust Strategy. As part of its consultation on priorities for improvement for the Annual Quality Report the Trust has liaised with clinical and managerial staff via divisional governance Board meetings and divisional review meetings. Key stakeholders, such as our FT membership, our governors, our local Healthwatch and local organisations from the third sector have been engaged via a stakeholder event to discuss the current year’s progress and priorities for the forthcoming year. The Information Team has also undertaken a triangulation exercise examining data sources that they regularly analyse for potential underlying issues of quality related to performance or data, not otherwise identified. All of the above has assisted the Trust be clear on its targets. Determining SMART objectives against our priorities is underway.

The Trust uses its systems for quality performance management to assess its performance in relation to regional and national comparators for the key quality indicators and associated narrative in the Quality Report. Information on quality is supplied to the Board, its committees and the management team by the Information and the Clinical Governance teams

This includes the implementation of technical controls such as industry standard next-generation firewalls, Intruder Prevention System, Internet Security Systems and Content Filtering Systems.

The technical security systems are configured to provide appropriate security protection as well as being monitored on a regular basis to ensure their effectiveness and include non-technical security controls for authorisation before granting users and systems access to data. ICT security staff work closely with the Information Governance team to ensure that ISMS is maintained and any new risks are addressed.

The Trust has had no data cyber-security/information governance incidents categorised at level 2 in 2015/16, therefore is not subject to any investigations by the Information Commissioners Office.

7. Annual Quality Report

The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS Foundation Trust Boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual.

The Trust’s commitment to quality improvement and quality governance is clearly outlined in its current clinical quality strategy; this describes a system of quality performance management, and a clear risk management

4. The Quality Report is shown in full, including the external auditor’s assessment, in Section 3.


Executive Directors and their senior managers; the BAF is then scrutinised quarterly at the ARC prior to being reviewed by the Board twice yearly.

> The BAF is reviewed and challenged as described in section 4 above. There is then an annual examination and refreshing of the principal risks. Internal audit have reviewed the BAF and risk management arrangements in 2015/16 and given reasonable assurance that the Trust has in place adequate and appropriate arrangements for gaining assurances about the effectiveness of the organisation’s system of internal control.

> The work of Internal Audit to review the Trust’s key processes of financial and non-financial internal control. The work-programme is risk based, and findings reported to the ARC. The Head of Internal Audit Opinion has given ‘reasonable assurance’ that there is a generally sound system of internal control designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls put the achievement of particular objectives at risk.

> A framework exists for the management and accountability of quality of performance data and data quality as detailed in section 7 above. This, together with the data audit results and input to the ARC, provides assurance to the Board on data quality and data performance issues and strength of internal control.

> The cost improvement plan is always a challenge, however the CAP and appropriate KPIs provides me with

for 2015/16.2) Trust Board Indicator assurance –

regular review and local auditing.3) A definitive list of all key datasets

and associated data quality assurance has been devised. This will direct the focus for the audit programme which will incorporate non patient datasets and those used for the quality accounts over 2016/17.

8. Review of 2015/16 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 that have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and 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 Risk Committee, the Quality and Safety Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place.

The process that is used to maintain and review the effectiveness of the system of internal control centres on:

> Development, review and challenge of the BAF which is compiled by Corporate Governance in conjunction with the relevant

A quarterly meeting with our local Healthwatch has supported discussion on the progress of our quality priorities and key quality indicators alongside hearing feedback from service users who access our services and who interact with Healthwatch. This assists in informing our quality improvement work.

A framework exists for the management and accountability of quality of performance data and data quality. This is supported by a comprehensive audit programme and the Data Quality Policy, which consist of a set of quality data groups that run across the organisation. These groups report to an Executive Director-led steering group which feeds quarterly into the ARC. These quarterly data quality and performance quality reports cover the Monitor compliance data, reported to the Board, and other key data sets used at key committees. This, together with the data audit results, and the use of Data Quality Badges which are described in each monthly performance report, provides assurance to the Board on data quality and data performance issues and strength of internal control. The integrated performance report in 2016/17 gives indications over quality metrics, early warning and trends to enable swift intervention to keep performance on track. The quality of elective waiting time data in particular will continue to be reviewed monthly at the elective performance meeting and divisional data quality groups, ensuring all elective lists are managed and assessed on electronic systems. Areas that have been identified this year where further actions are being implemented:

1) NHS Number coverage on clinical systems – the programme to integrate information systems is continuing to address this with seven remaining systems identified


2.7Given the National and London position with regard to the A&E 4 hour target, if the current levels of high demand continue into 2016/17 this will remain a significant challenge for our Trust alongside the threshold for C. difficile, which has been set at 8 cases for 2016/17.

9. Conclusion

My review confirms that The Hillingdon Hospitals NHS Foundation Trust has a generally sound system of internal control that supports the achievement of its policies, aims and objectives. No significant internal control issues have been identified, however a requirement notice against regulation 12; “safe care and treatment”, specifically focused on infection and prevention has been applied to our Trust. The Trust Board continues to proactively drive forward agreed actions to attain compliance with CQC regulations.

I can also confirm that, having taken all appropriate steps to be aware of any relevant audit information that should be communicated, and to the best of my knowledge, there is no relevant audit information of which our external auditor, Deloitte LLP has not been made aware.

I consider that any significant issues are included in the report, namely: condition of the Trust estate; The CQC requirement notice, against regulation 12; “safe care and treatment”, specifically focused on infection and prevention and increased demand affecting emergency department performance.


assurance that clinical quality should not be compromised.

> The 4 hour A&E target was under pressure throughout the financial year despite joined up work across the Health and Social Care system.

> The Trust exceeded the zero tolerance threshold for MRSA with one positive case reported. On further investigation however this case was found to be a blood culture specimen contaminate rather than a true MRSA bacteraemia.

> The Trust exceeded the C. difficile trajectory of eight with a total of 12 cases. Mitigations included: Delivery of the Infection Prevention & Control annual action plan and continuing to embed the ‘Start Smart, Then Focus’ antimicrobial prescribing guidance. Each Trust attributed CDI case, through the Root Cause Analysis (RCA) process, was assessed with actions generated by this process being implemented in a timely way. Only one of these cases was deemed a ‘Lapse in Care’ as agreed with our commissioners; the other eleven cases were treated appropriately and there was no evidence of cross infection or inappropriate infection control practice. Infection control rates are reviewed by the Infection Control Committee, QSC and the Board.

> The Trust managed to attain a Financial Sustainability Risk Rating score of at least 2 throughout the year.

On balance, I therefore conclude that the Board has conducted a review of the effectiveness of the Trust’s system on internal control and found them to be effective. I am satisfied that the measures that have been put in place following the CQC inspection findings addresses the issues raised with respect to regulatory compliance.


3 Quality report2015/16Putting Compassionate Care, Safety and Quality at the heart of everything we do


3

cont

ents

About the Trust’s Quality Report

Executive summary

Part 1 Statement from the Chief Executive

Part 2 Priorities for improvement and statements of assurance from the board 2.1 Review of Quality Priorities for Improvement Key Quality Achievements for 2015/16 Looking back…

Quality priorities for improvement 2015/16 – How did we do?

Looking Forward… Quality priorities for improvement in 2016/17 2.2 Formal statements of assurance from the Board Provision of NHS Services Participation in clinical audit Commitment to research as a driver for improving the quality of care and patient experience Lessons learned from Serious Incidents Statutory Duty of Candour – Key recommendation from the Francis Inquiry Goals agreed with our commissioners Care Quality Commission registration Data quality Information governance toolkit Clinical coding error rate 2.3 Performance against Core Quality Indicators 2015/16

Part 3 Other key quality improvements we have made in 2015/16

Annex 1 Statements from our stakeholders

Statement from Hillingdon Clinical Commissioning Group (CCG) Statement from our local Healthwatch Statement from External Services Scrutiny Committee The Hillingdon Hospitals NHS Foundation Trust response to the consultation Independent auditor’s report to the council of governors of The Hillingdon Hospitals NHS Foundation Trust on the quality report

Annex 2 Statement of Directors’ responsibilities in respect of the Quality Report

Glossary


developing this report to ensure that the quality improvement priorities reflect those of our patients, our staff, our partners and the local community.

Part 2 of the report highlights the Trust’s quality priorities and includes:

> The areas identified for improvement in 2015/16;

> How we performed against these improvement targets

> What this means for our patients.

What is included in the Quality Report?

The Quality Report is a statutory document that contains specific, mandatory statements and sections. There are also three categories mandated by the Department of Health (DH) that give us a framework in which to focus our quality improvement programme. These are patient safety, patient experience and clinical effectiveness. The Trust undertook extensive consultation in

About the Trust’s Quality Report

There is also a section in Part 2 on the quality priorities that have been identified for improvement projects in 2016/17.

A glossary is available at the back of the report which lists the abbreviations and terms in the document.

What is the Quality Report?

The Quality Report is produced by NHS healthcare providers to inform the public about the

quality of services they deliver. As a Trust we strive to achieve high quality care for our patients.

The Quality Report provides an opportunity for us to demonstrate our commitment to quality

improvement and show what progress we have made in 2015/16 against our quality priorities

and national requirements. The Quality Report is a mandated document which is laid before

Parliament before being made available on the NHS Choices website and our own website –

(www.thh.nhs.uk).


3However 2015/16 has been a challenging year for the Trust. We have seen increased patient activity and throughput with 32 additional beds open. This has put pressure on our internal systems and has stretched our manpower resources during a very challenging staffing market nationally. It has therefore been difficult to realise some of the stretching quality targets that we set ourselves at the beginning of the year.

Some examples of our achievements and progress against key priority areas are listed in the table overleaf.

Some elements of improvement work in the key priority areas have not been realised and the clinical teams will continue to drive forward improvement during 2016/17 to ensure the improvement targets are achieved. In addition the Trust will develop a refreshed CQC action plan for 2016/17 based on the outcomes of mock CQC

This Executive Summary provides a very brief overview of the information in this year’s report.

The report provides a summary of performance during 2015/16 in relation to quality priorities and national requirements. Overall, the Trust has performed very well in 2015/16 across a wide range of quality indicators. Particular successes include:

> An improvement in our mortality rates with a reduction in the variability between weekdays and weekends

> A reduction of more than 30% for Clostridium difficile (C. diff) infections from last year’s figures

> Cancer performance indicators demonstrating better than London and national averages

> Improved patient satisfaction as measured by the Friends and Family Test (FFT)

> An improved patient safety incident reporting rate and a ‘good’ rating in the ‘Learning from Mistakes League’.

We have also performed well in other areas including increasing our uptake of statutory and mandatory training and achieving the requirements of the National Specifications for Cleaning across the Trust as part of our Care Quality Commission (CQC) improvement programme.

Executive summary

inspections conducted by our staff during the year. Our ambition will be to achieve an ‘outstanding’ rating, with a minimum of good, at a future CQC inspection.

We have set out our quality priorities for 2016/17 and we aim to achieve the following:

1. Achieving NEWS compliance

to support early escalation of

the deteriorating patient

2. Achieving improvement

in relation to seven day

working priorities

3. Delivering compassionate

care and improving

communication

4. Safer staffing – improved

recruitment and retention to

ensure delivery of safe care

NEWS – National Early Warning Scoring System (see glossary at end of report)


Quality Priority How did we do?

Priority 1: Ensuring the safety of vulnerable and older people

Increase number of relevant staff receiving the enhanced Mental Capacity Act/Deprivation of Liberty Safeguards (DoLS) training.

We have achieved 81% against a target of >80%.

Establish an Equality and Diversity (E&D) steering group with representation from people with different disabilities.

An E&D steering group has been established and a task and finish group focusing specifically on physical and sensory disability is to be established.

Improve the engagement with people who have a disability by attending local groups for people with disabilities.

We have attended local disability groups and information has been provided on areas for improvement for physical and sensory disabilities.

Priority 2: Improving the safety of medicines management

Increase reporting of medicine errors - Medication Related Incidents as a % of all Patient Safety Incidents*

Behind plan. We have achieved 9% against a target of >11%. However this is an improvement from 2014/15 performance of 7.8%.

Develop a pharmacy services patient questionnaire, establish a baseline, audit quarterly and realise improvement for 2015/16 on the baseline.

Achieved. We have achieved 85% satisfaction with the service against a target of 75%.

Priority 3: Improving maternity services

10% reduction in complaints received on maternity triage service once this has moved to its new clinical environment.

We have seen an improvement in women’s satisfaction of the service with approximately 30% fewer complaints received.

A very positive experience for women in the new birth centre monitored via the FFT.

We achieved 97% satisfaction against a target of >88%.

Maintain current numbers of Hillingdon Borough women choosing to continue to use The Hillingdon Hospital.

All Hillingdon women have been able to access the service during 2015/16.

Priority 4: Improving communication with our patients

Improvement on communication and information provided to patients in the Accident & Emergency (A&E) department.

Achieved. We continue to receive very positive feedback about people’s experience in our A&E department via the Friends and Family Test.

Discharge summaries from inpatient episodes will be completed within 24 hours - >80% target.

We are behind plan at 57% compliance. 98.7% of discharge summaries are completed but further work is required to ensure this happens within a 24 hour timeframe.

Involved as much as you wanted to be Behind plan. Achieved 84% against a target of 89%. It is disappointing that we have not been able to achieve the stretching target that we set ourselves based on an improved position in 2014/15. Activity and demand for A&E and inpatient services has put pressure on existing staffing resources and impacted upon our ability to make improvement in this key area of patient experience.

Nurses - clear answers to questions – achieved 87%Doctors - clear answers to questions – achieved 86%

Behind plan. Achieved 87% and 86% against a target of 90%.The reasons for not fully achieving are as above with regard to increase in activity and pressure on existing staffing resources.

*A higher reporting rate represents a stronger patient safety culture


3We have also been working closely with our partners in health and social care and key stakeholders to deliver improvements in the services delivered across North West London with regard to the Shaping a Healthier Future (SaHF) programme and the Whole Systems Integrated Care (WSIC) project supporting new care models to ensure an improved quality of person-centred care.

The mandated sections within this Quality Report include information on our participation in national audits and our research activity during 2015/16. In addition, information is provided on our registration as a healthcare provider with the Care Quality Commission (CQC) and the progress we have made in response to the findings of their inspection of October 2014 and their re-visit of May 2015.

This Quality Report and the priorities for 2016/17 are presented as a result of consultation and engagement with Foundation Trust members, our governors, patients and the public, our staff, our local Healthwatch and our Commissioners.

with colleagues as part of the Imperial College Healthcare Partners Academic Health Science Network.

During 2015/16 the Trust has taken forward a detailed action plan to support its ‘Sign up to Safety’ (SU2S) campaign. SU2S aims to strengthen patient safety in the NHS with a three year objective to reduce avoidable harm by 50% and save 6,000 lives. The Trust’s campaign has been aligned to our clinical quality strategy and our commitment to listen to patients, carers and staff, to learn from what they say and to take action to improve patient safety. The Trust follows national guidance on the investigation of patient safety incidents and the Trust has clearly defined processes and procedures to follow to help to reduce the risk of these events occurring. Where a Serious Incident does occur, lessons need to be learnt through a process of root cause analysis investigation. Some of the learning from these Serious Incidents is outlined later in the report.

The key indicators that we are aiming to achieve under these priorities are outlined in the main report.

During 2015/16 there has continued to be increased focus on measuring and monitoring the quality of our services and the care that is delivered to our patients and their families. The Trust’s Clinical Quality Strategy 2013-16 has supported this work and helped us to achieve our vision: ‘To put compassionate care, safety and quality at the heart of everything we do’.

The Trust will implement a revised Quality and Safety Improvement Strategy for 2016-19 as informed by the Trust Quality and Safety Committee’s own review of effectiveness and recommendations arising from the Trust’s CQC inspection in October 2014. The strategy will clearly articulate our ambitious aims across the domains of patient safety, clinical effectiveness and patient experience. Our quality improvement work will be informed and supported by learning from and collaboration

SU2S aims to strengthen patient

safety in the NHS with a three year

objective to reduce avoidable harm by

50% and save 6,000 lives.

50%


> A reduction of more than 30% for C. diff infections from last year’s figures

> We received more than 25,000 responses to the Friends and Family Test (FFT) during 2015 and 93% of patients said they were happy to recommend our services to their friends and family

> Our score for staff engagement was 3.86 out of 5, an increase on our 2014 score but also above the national average. Overall, we scored above average in 18 areas out of a total of 32 with 10 of these being in the top 20% of all acute Trusts in England.

We have also continued to invest in our services, some exciting developments include:

> More than £3 million investment to improve and expand our children’s services as part of the Shaping a Healthier Future programme. Improvements include delivering a new children’s A&E, and four new beds on Peter Pan Ward

> More than £1 million was invested in establishing a new Nuclear Medicine Facility housing the latest SPECT CT scanner. This enables nuclear and CT scans to be carried out at the same time reducing the need for multiple patient scans

> The Trust created a £240k state-of-the-art simulation suite, featuring high-specification robotic model patients, ensuring staff can develop and improve their skills in a safe and supportive environment.

Many examples of good practice are highlighted within this report and I welcome the very positive feedback provided by patients and staff. Whilst it is important to acknowledge the challenges we have faced and where we have not been able to fully achieve the targets we have set, we must also remember that there is a great deal to celebrate and commend and our staff should feel proud of their effort and achievements.

The last year has seen the Trust perform well in many areas. This includes:

> The Referral to Treatment (18 weeks) waiting times performance standards were changed this year and the Trust continues to maintain its high performance against this standard

> Key cancer performance indicators are being well maintained for all the national waiting times standards, and performing better than the London and national average

> An improvement in our mortality rates with a reduction in the variability between weekdays and weekends

Nationally, the NHS has had a difficult year, and has struggled to meet key performance targets in the face of unprecedented levels of emergency demand. Locally, it has also been a challenging year for the Trust in continuing to drive forward key improvements in response to the findings of the CQC inspection of October 2014 alongside higher activity. Our staff have worked tirelessly to implement improvements alongside continuing to deliver high quality and safe care for patients.

The Trust has responded extremely well in the last year to the requirements outlined in the CQC report of January 2015. By May 2015 we were able to demonstrate significant improvements and the two Warning Notices,issued for Regulation 10 – Assessing and Monitoring the Quality of Service Provision and Regulation 12 – Cleanliness and Infection Control, were removed by the CQC. In addition, the ‘inadequate’ rating for the safety domain was upgraded to ‘requires improvement’. I am pleased with the great progress that was made in a relatively short space of time; this was due to the commitment and dedication of our staff.

Part 1: Statement from the Chief Executive

This Quality Report provides the Trust with an opportunity to demonstrate its commitment to delivering high quality care and outlines the improvements that have been made during 2015/16.


3the expansion, including obstetric consultant cover and the appointment of a consultant midwife.

Currently the Women and Children’s Division is planning the transition of the Paediatric services as part of the SaHF programme which is due to complete in June 2016.

In April 2015 we saw the launch of the Hillingdon’s Whole Systems Integrated Care project (WSIC) - a comprehensive new care model coordinating care across all providers, centred around patients over 65 years old. The Trust has been a significant partner in developing and delivering the programme to date and will continue

for our emergency services has increased by 2.6% during 2015/16; this is in addition to a 9% growth seen in emergency attendances in 2014/15. The number of category 1 (blue light) ambulances attending the Trust has increased by 22.8% year to-date. This upward trend began in April 2014. Since that time blue light activity has increased by 53%.

The Trust has expanded and developed its maternity services to accommodate changes as a result of the closure of Ealing Maternity Services under the Shaping a Healthier Future (SaHF) agenda. We have responded effectively to the increase in demand resulting from the changes including the development of a midwifery-led unit and expansion of the maternity triage service and the community midwifery and specialist teams. We have also seen an increase in both obstetric and midwifery staffing numbers to support

I am proud that we have also received national recognition for outstanding core skills compliance by the London Streamlining Programme (collaboration between HR for London, NHS Employers and Skills for Health). This recognises that we raised our mandatory training compliance levels to over 90% and maintained this over the last year.

The Trust rated green (compliant) throughout the year in all but one (A&E four-hour target) of Monitor’s key performance targets. Overall demand


to work hard to ensure the model is further refined and rolled-out across the borough to benefit as many people as possible. Substantial progress was made during 2015/16, and plans are in place to accelerate the programme during the coming year. A key milestone in this work was the establishment of an Accountable Care Partnership (ACP) involving all of the main care providers in Hillingdon. In developing our quality priorities for 2016/17 we have made reference to our latest CQC report, national best practice and reviewed our current

There are a number of inherent limitations in the preparation of this Quality Report which may impact the reliability or accuracy of the data reported. These include:

> Data is derived from a large number of different systems and processes. Only some of these are subject to external assurance, or included in internal audits programme of work each year

> Data is collected by a large number of teams across the Trust alongside their main responsibilities, which may lead to differences in how policies are applied or interpreted. In many cases, data reported reflects clinical judgement about individual cases, where another clinician might have reasonably classified a case differently

> National data definitions do not necessarily cover all circumstances, and local interpretations may differ

> Data collection practices and data definitions are evolving, which

may lead to differences over time, both within and between years. The volume of data means that, where changes are made, it is usually not practical to reanalyse historic data The Trust’s Board and management have sought to take all reasonable steps and exercise appropriate due diligence to ensure the accuracy of the data reported, but recognises that it is nonetheless subject to the inherent limitations noted above.

Following these steps, to my knowledge, the information in the document is accurate.

Shane DeGarisChief ExecutiveThe Hillingdon Hospitals NHS Foundation Trust

quality performance in line with local, regional and national performance. We have also consulted with a wide group of stakeholders, including our governors, Commissioners, People in Partnership and our local Healthwatch. Our aim is to continue to focus on the essentials of care in order to continue to improve clinical outcomes and to ensure that our patients have a positive experience.

We remain, as always, grateful for the ongoing commitment and contribution of patients, staff, governors, members, Commissioners and other stakeholders in supporting our quality improvement goals. We

are working at a time of challenging financial constraints in the NHS and it has never been more important to focus on our patients’ experience of their care and evidence of clinical effectiveness to improve quality continually.

I am clear that our hospitals have staff who are committed to the highest possible standards of care for our patients. I hope that this Quality Report confirms our commitment to you to achieve improvement in the quality of our services to patients and ensures that we always put our patients at the forefront of service development and improvement.


3

Key Quality Achievements in 2015/16

> An improvement in our mortality rates with regard to levelling weekend and weekday mortality rates compared to last year

> A reduction of more than 30% for Clostridium difficile infections from last year’s figures

> Cancer performance indicators demonstrating better than London and national averages

> High patient satisfaction with 95% recommending an inpatient ward and 93% recommending our Accident and Emergency department as measured by the Friends and Family Test

> An improved patient safety incident reporting rate and a ‘good’ rating in the ‘Learning from Mistakes League’ published by Monitor and the NHS Trust Development Authority in March 2016.

Part 2 – Priorities for improvement and statements of assurance from the Board

2.1 Review of Quality Priorities for Improvement

In this part of the report we tell you about the quality of our services and how we have

performed in the areas identified for improvement in 2015/16. These areas are called our quality

priorities and they fall into the three areas of quality as mandated by the Department of Health

(DH): patient safety, patient experience and clinical effectiveness; we are required to have a

minimum of one priority in each area.

Firstly, the information below provides an overview of some of our key quality achievements

in 2015/16. These are important indicators for the public and our key stakeholders to provide

assurance on the quality of care and services that are delivered at the Trust:


This element of care was identified by our key stakeholders as requiring improvement and concerns were also referenced via our complaints service in the feedback we get from patients and their families/carers.

How did we do? The specific goals that we set and the performance during 2015/16 are outlined in the table below.

What does this mean for our patients?These changes mean that our patients now experience a service which is more responsive to their specific needs,

PRIORITY 1

Safeguarding – Ensuring the safety of vulnerable and older people

We said:We wanted to work with social care and community colleagues on improving discharge management for vulnerable and older people. We said we wanted to identify improvements for people with disabilities and the frail elderly in hospital and for those people who may lack the capacity to consent or who lack advocacy.

LOOKING BACKQuality priorities for improvement 2015/16 – How did we do?

Quality Priority indicators 2015/16 performance

Establish a baseline on the number of referrals to the Independent Mental Capacity Advocacy (IMCA) service and realise an increase in these numbers.

Referrals generated to the IMCA service during 2015/16 totalled 14 cases across Q1-Q3, Q4 figures awaited (Q1=6, Q2=3 and Q3=5)This information has not been collected previously so this supports the Trust in now having a baseline to monitor use of the service.

Data source: PohWER report to London Borough of Hillingdon.

Establish a baseline on the number of referrals to the Disablement Association Hillingdon (DASH) service and realise an increase in these numbers.

We have been unable to access this information via the DASH service however the Trust regularly involves DASH in discussions and when designing and developing new services.

Further increase the number of staff receiving the enhanced MCA/Deprivation of Liberty Safeguards (DoLS) training - >80% for relevant staff.

Achieved 81% against a target of 80%.

Establish an Equality and Diversity (E&D) steering group with representation from people with different disabilities.

An E&D steering group has been established and a task and finish group focusing specifically on physical and sensory disability is soon to be established.

Improve our facilities for those people with physical and sensory disabilities, such as increased number of hearing loops in use, improved signage and improved access to interpreting services, especially British Sign Language

A hearing loop system has been installed in more areas across the hospital; signage improved based on feedback; translation services reviewed.

Improve the engagement with people who have a disability by attending local groups for people with disabilities (DASH and the Hillingdon Disabled Tenants and Residents Group).

We have attended local disability groups and information from these has been provided on areas for improvement with regard to physical and sensory disability.


3PRIORITY 2

Improving the safety of medicines management and improve the experience of people requiring medicines in the inpatient and outpatient setting

We said:The Trust is committed to ensuring that patients are able to continue to take their medicines safely after leaving the hospital. We highlighted that allowing patients to continue to take their medicines themselves (self-administration) whilst they are in hospital (where they are able to do so) is an important element of medicines adherence and compliance. Maintaining independence in this way means that there is a reduced risk of readmission to the hospital due to medicines-related reasons.

In addition we reported that the Trust is committed to optimising the safe use of medicines and central to this is to ensure that learning from most errors/near misses of no harm are applied to reduce the risk of errors/near misses occurring that may cause harm.

loops across both hospital sites. The introduction of the hearing loop system both improves privacy, dignity and well-being under PLACE and meets the requirements of the Equality Act (2010) requiring organisations to make all reasonable adjustments to provide deaf or hard of hearing people with full access to services.

Signage has been improved across both sites to reflect feedback on new services, clinical department moves and much of the signage (particularly for toilets, entrances, exits, lifts) has been altered to ‘black text on a yellow background’ to support people with dementia. In addition the Trust now has a contract with One Stop Language Services for the provision of British Sign Language (BSL) for patients using our services.

Focus groups have been held with a group of service users who have either a sensory or physical disability.Representatives from the Hillingdon Disabled Tenants and Residents Group have been invited to be involved in the relocation project for the outpatient pharmacy.

A new Disability Discrimination Act (DDA)/Equality Act survey for both hospital sites is to be commissioned in the forthcoming year. Once this survey has been carried out the key actions will be evaluated, risk assessed and prioritised for funding along with other legislative requirements.

especially where patients are more vulnerable and may lack the capacity or the ability to advocate for themselves.

In relation to the IMCA service, awareness has been raised in many ways across the Trust. The importance of using an IMCA for patients without capacity is discussed within Safeguarding Adult training sessions and information about the referral process and forms are available on the safeguarding adults’ intranet page for staff to access. The Head of Safeguarding has good links with the local IMCA service delivered by POhWER (advocacy agency) on behalf of the local authority.

The local IMCA liaises directly with wards and departments who have referred patients for the service. Their workload has significantly increased since the Deprivation DoLS Cheshire West judgement and the subsequent increase in DoLS referrals nationwide. The role of the IMCA is clearly stipulated within the Trust’s MCA and DoLs policy. Contact details are also given for the DASH advocacy service for patients who need support and do have capacity to make decisions.

One of the focus groups looking at physical and sensory disability and accessibility to our services took place at DASH and was attended by service users providing valuable feedback on the Trust services. This will support us taking forward our improvement plan around disability.

Following the 2015 PLACE (Patient Led Assessments of the Care Environment) inspections, the patient assessors identified that many patient/public reception areas did not have hearing induction loops. The hearing loop is a special type of sound system for use by people with hearing aids to enable them to hear more clearly. As a result the Facilities department arranged for the installation of sixteen new hearing

A new Disability Discrimination Act (DDA)/Equality Act survey for both hospital sites is to be commissioned in the forthcoming year.


across North West London including Hillingdon as part of the Shaping a Healthier Future (SaHF) programme.

How did we do? Key aims we want to achieve in relation to the women’s experience are outlined below.

What does this mean for our patients?The substantial increase in activity as part of the transition of Ealing Maternity services has required in-depth planning and robust implementation to ensure a safe and effective service. This work has involved the implementation of new service models such as a midwifery-led birthing centre, ambulatory pathways, a new community team and a transitional care unit.

The Trust has wanted to ensure that all women accessing maternity services at Hillingdon whether they are from within or outside of the borough have a positive experience in relation to

our new Medication Safety Officer leading this agenda and working with key clinical and management leads. Key actions will include improved training, establishing medicine safety champions, prescribing tips for doctors based on learning from prescribing errors and a drive to further increase medicine incidents reporting to aid learning and improvement.

PRIORITY 3

Improving Maternity Services

We said:The Trust wanted to ensure that all of the women accessing our maternity services would have a positive experience in relation to their care and treatment. This was particularly important in relation to increasing the number of deliveries at Hillingdon from 4,100 to 5,000 babies. This was due to the re-allocation of Ealing maternity services to other maternity units

How did we do?The specific goals that we set and the performance during 2015/16 are outlined below.

What does this mean for our patients? Improving the safety of medicines management in hospital is key to ensuring patient harm is reduced and that patients receive the medicines they are prescribed. Ensuring patients are empowered to take their own medicines whilst in hospital where this is appropriate will help adherence to medicines especially when the patient is being discharged home. The Self Administration of Medicines (SAM) policy will be published once ratified in May 2016 based on feedback we have received with roll out of self-administration of medicines thereafter across the Trust.

The work to ensure improved safety in relation to patients’ medicines will continue in this forthcoming year with

Quality Priority Indicators 2015/16 Performance

Pilot the use of the revised patient self-administration of medicines policy and roll out its implementation across the Trust.

This work remains in progress. The pilot was completed. Feedback from staff varied in highlighting issues in process and/or shortfall in facilities to safely implement the existing Self Administration Medicines (SAM) Policy.Therefore roll out has been delayed until the revised policy has been ratified by end of May 2016.

Develop survey and receive qualitative feedback from staff and patients on self-administration of medicines (SAM) in hospital and demonstrate evidence of changes to the process based on this feedback.

This work is in progress. A structured staff survey was devised and has been completed. The information was used to inform the revision of the SAM Policy as above.

Increase the reporting of medicines errors, via our incident reporting system, that constitute no/low harm incidents so that learning from these can avoid more harmful incidents from occurring. The Trust aim will be to improve on current performance to achieve the national average of 11%*.

This work remains in progress. We have achieved 9% against a target of >11%. This is an improvement from 2014/15 performance of 7.8%. A Medication Safety Officer has now been employed to lead this work to achieve our target during 2016/17. Recent data published in April 2016 from the National Reporting and Learning System (NRLS) shows that we are now near to the national average.

Develop a pharmacy services patient questionnaire, establish a baseline, audit quarterly and realise improvement for 2015/16 on the baseline.

We have achieved 85% satisfaction with the service against a target of 75%.

*A higher reporting rate represents a stronger patient safety culture


3

> ‘not always able to get help from a member of staff particularly in relation to breastfeeding support’ – now rectified by the employment of Infant Feeding lead and a robust training programme which has helped us achieve a month on month improvement in initiation rates and six-week postnatal rates

> Hospital rooms/toilets/bathrooms not clean - we are working closely with the cleaning teams and ward sisters to ensure compliance with cleaning standards. This remains an ongoing work in progress.

We will be undertaking a mock Picker Survey for women who delivered this February (2016) to measure any improvement in service following the transition of Ealing patients and having filled the senior posts that had been left vacant. As outlined above the service receives highly positive responses in the Friends and Family Test. The service has worked hard to improve response numbers which has been a challenge however it is now achieving above the planned target each month.

Maternity Experience Survey The Maternity Picker Survey, published in October 2015, was sent to women who delivered their baby in February 2015. Unfortunately the 2015 survey showed a decline in the womens’ experience compared to the previous report of 2013. This is in contrast with the results received via the Maternity FFT. Although not complacent with regard to the results of the Picker survey, the service has identified that there were mitigating circumstances linked to the SaHF transition planning where vacancies for senior midwifery posts were not allowed to be filled as part of TUPE (Transfer of Undertakings (Protection of Employment) Regulations) - Ealing Senior Midwives were offered vacant posts across the sector. This meant that key leadership roles were left vacant. This included the Postnatal Ward Sister, Infant Feeding Midwife and two community team leader posts.

A couple of common themes identified in the survey were:

their care and treatment. We believe the changes we have implemented have improved the quality of care and choice for all women choosing to have their baby with us.

The service currently receives positive feedback through the Friends and Family Test (FFT) across all our services. The challenge so far has been the limited number of respondents from service users in the community following the delivery of their baby. A lot of work has been undertaken to increase the number of responses in order to obtain adequate feedback to help shape our services.Following this work there has been a steady increase in the number of respondents providing feedback. We have started displaying ‘you said, we did’ posters based on the feedback received from FFT, NHS Choices, verbal feedback and complaints. We will continue to encourage responses and act on feedback going forward.All complaints have an action plan, where concerns have been identified and learning from the investigations is shared with all staff groups to further improve the quality of the service.

Quality Priority Indicator 2015/16 Performance

A 10% reduction in the complaints received on the maternity triage service once this has moved to its new clinical environment

We have seen an improvement in women’s satisfaction of the service with approximately 30% fewer complaints received.

A very positive experience for women in the new birth centre monitored via the Friends and Family Test – target of >88% extremely likely/likely to recommend


Very positive feedback from women on the new neonatal transitional care model -target of >88% extremely likely/likely to recommend via the FFT


Maintain current numbers of Hillingdon Borough women choosing to continue to use the Hillingdon Hospital service, despite the increase in Ealing women accessing the maternity services at Hillingdon.

All Hillingdon women have been able to access the service during 2015/16.

We achieved 97% satisfaction

against a target of >88% from

women on the new neonatal

transitional care model.


they receive clear answers to questions by all healthcare professionals continues to be a key priority for the Trust as part of our patient experience improvement work. It is disappointing that we have been unable to improve our performance in the key patient experience indicators that we identified for improvement in 2015/16. As a result we will be continuing to focus on these areas and aim to achieve an improvement in 2016/17 as part of Priority 3 – Delivering compassionate care and improving communication.

How did we do? The specific goals that we set and the performance during 2015/16 are outlined below.

Within the A&E we continue to receive in the main very positive feedback about people’s experience of using our services via the Friends and Family Test survey. We are mindful however that we need to increase the number of patients who provide this feedback and act upon it in a meaningful way. Ensuring patients are involved and that

PRIORITY 4Improving communication with our patients

We said: We wanted to ensure that there is continuing focus on improving the patient experience and that services that are delivered are truly responsive to individual patient needs. Feedback from a variety of sources including our complaints service indicated that communication from the healthcare team to the patient and their family/carers, as a key patient experience element, still needed to improve.

Quality Priority Indicator 2015/16 Performance

Improved communication from the A&E department:

Quarterly audit of quality of A&E discharge summary, demonstrating improvement in standard of information provided.

Staff have been unable to complete the quarterly audit as planned due to the increase in activity within the department. There has however been discussion and progress within the department on further improvements required as a result of the previous audit undertaken earlier in 2015.

Improvement on communication and information provided to patients in A&E

We continue to receive very positive feedback via the FFT about the A&E service - 93.4% satisfaction YTD (March).

Copy of discharge summary provided to patients attending A&E department before they leave

Behind plan. Despite our best efforts this proves to be a very challenging standard to meet with the current activity of the service. The patient’s GP receives an electronic summary within 12 hrs of the patient’s attendance.

Discharge summaries from inpatient episodes will be completed within 24 hours - >80% target

Behind plan. We have achieved 57% within 24 hrs. 98.7% of discharge summaries are finally completed but not within the 24 hours.

Improvement in the results of the local quarterly patient experience survey in the following areas*:

Involved as much as you wanted to be (Target - 89%) Behind plan. Achieved 84% against a target of 89%. It is disappointing that we have not been able to achieve the stretching target that we set ourselves based on an improved position in 2014/15. Activity and demand for A&E and inpatient services has put pressure on existing staffing resources and impacted upon our ability to make improvement in this key area of patient experience.

Nurses - Clear answers to questions (Target - 90%) Behind plan. Achieved 87%. As above.

Doctors - Clear answers to questions (Target - 90%) Behind plan. Achieved 86%. As above.

If waiting more than 20 mins, informed and updated of waiting times (Target - 80%)

Behind plan. We achieved 63.3% against a target of 80%. Further improvements are required in specific departments to improve this score across the Outpatient department as a whole (namely the Eye department and the Mount Vernon Treatment Centre).

*Based on data available July 2015 and March 2016 – 2000 responses


3restricted and fragmented. There are three separate waiting areas and as a result the patient’s journey is complex. When a clinic delay is announced the patient may just have been moved to another area for clinical input and may miss the announcement. At the Mount Vernon Treatment Centre we rely on the Savience system display to advise patients of delays. There are TV screens for patients to see this display which are positioned in two different areas however patients may miss this display depending on where they are sitting.

Actions moving forward include Mount Vernon Treatment Centre staff using a Tannoy system in addition to the displays via the Savience system. Staff in the Eye Department will be encouraged to inform patients at each step of their journey through the department.

The Trust participates in the annual national patient survey programme and in addition a number of local patient surveys have also been developed and implemented. The Friends and Family Test has also been fully rolled out to all patient areas.We aim to be a listening and learning organisation, in which concerns that are raised by patients are understood, shared and responded to. Listening to feedback enables our staff to gain a real insight into the patient’s experience of care. Involving the patient as much as possible in their care supports an improved experience for patients and assists in maintaining their safety; effective communication is a key part of this.

30 minutes at the end of their shift to ensure compliance with this standard.

The completion of inpatient discharge summaries (letters) within an acceptable timeframe has proved to be a challenge during 2015/16 across the Trust. This causes delayed communication to GPs and potential delay in further follow-up or treatment. A detailed investigation has been undertaken into why delays are occurring and a comprehensive action plan will be taken forward in 2016/17 to resolve the backlog of summaries and ensure a robust system moving forward.

With regard to waiting time in the Outpatient department we achieved 63.3% against the 80% target for patients being informed and updated about delays. There are two clinical areas that contribute significantly to this position which are the Eye Department and the MVH Treatment Centre. Some of the contributing factors that affect the results for these two areas include the environment of the Eye Department which is very

The new A&E nurse consultant is going to undertake some specific projects to improve communication with patients and their families and to increase the opportunities for feedback from patients and carers in the first quarter of 2016/17. These include introducing electronic tablets to capture feedback alongside the paper survey, more thorough review of patient responses and actions being taken and a league table for A&E teams with regard to numbers and results of responses received by each team.

Despite our best efforts in ensuring a discharge summary is provided to each patient that has attended A&E, and within 24 hours to their GP, this remains a very challenging standard to meet within the activity of the A&E service. Overall there has been a steady improvement and now 98.7% of patients leaving the Clinical Decisions Unit within the A&E department receive a copy of their discharge summary albeit not within 24 hours of discharge. Moving forward it has been agreed that each doctor is allocated


and effective at all times. The five key Sign up to Safety campaign pledges are listed below:

> Put safety first – commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally.

> Continually learn – make organisations more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe their services are.

> Honesty – be transparent with people about their progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong.

> Collaborate – take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use.

> Support – help people understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress.

The Trust is continuing to drive forward this work. A steering group has been meeting regularly to review progress and key actions that have been completed include:

> A Sign up to Safety launch event was held in June 2015 to raise awareness of the campaign. Clinical teams were able to share the excellent patient safety improvement work that is already in progress with our patients

> A patient engagement event focusing on patient safety and the Patient Safety Champion role was held in October 2015

> A staff workshop was held in November 2015 focusing on patient safety incident reporting and the role of the Staff Champion for Safety

> A staff safety culture survey and a patient engagement in safety survey were conducted

recommendations arising from the Trust’s CQC inspection in October 2014. The strategy will clearly articulate our ambitious aims across the domains of patient safety, clinical effectiveness and patient experience. Our quality improvement work will be informed and supported by the learning from and collaboration with colleagues from across the North West London sector as part of the Imperial College Healthcare Partners Academic Health Science Network. Our six quality aims as part of our new strategy are as follows:

1. No Preventable Deaths2. Proactively improving systems to

reduce harm3. Improving patient experience as

defined by our patients4. Achieving the best possible

outcomes for patients5. Ensuring people receive care in the

right place6. Developing a safety culture in

which safety is everyone’s business

Our Sign up to Safety Campaign

Towards the latter part of 2014 the Trust signed up to the national patient safety campaign that was launched by the Secretary of State for Health. ‘Sign up to Safety’ is a campaign to strengthen patient safety in the NHS. Its three year objective is to reduce avoidable harm by 50% and save 6,000 lives. In 2015/16 the Trust developed a detailed plan outlining the work we would take forward to reduce harm and save lives; this was aligned with the Trust’s clinical quality strategy.

As part of this work the Trust has committed to: listen to patients, carers and staff, learn from what they say when things go wrong and take action to improve patients’ safety. We want to give patients confidence that we are doing all we can to ensure that the care they receive will be safe

LOOKING FORWARD

Our Clinical Quality Strategy

During 2015/16 we have continued to focus on measuring and monitoring the quality of our services and the care that is delivered to our patients and their families. The Trust’s three-year Clinical Quality Strategy has supported this work and has helped us to achieve our vision ‘To put compassionate care, safety and quality at the heart of everything we do’. The strategy has provided a structure for ensuring strong clinical governance and ongoing improvement in the quality and safety of patient care. A clinical quality strategy action plan has been reviewed on a quarterly basis at the Quality and Safety Committee (Board committee). Clinical divisions developed local quality actions plans based on the overarching Trust action plan. These formed part of their business plans and were used to monitor progress at their divisional performance reviews.

The clinical quality strategy also outlines the responsibilities of Trust staff and is supported by our culture and values framework, CARES (Communication, Attitude, Responsibility, Equity and Safety) which embraces a culture that empowers staff to report incidents and raise concerns about quality and patient safety in an open, blame-free working environment. This is supported by the statutory Duty of Candour and best practice guidance such as ‘Freedom to Speak’.

The Trust will implement a revised Quality and Safety Improvement Strategy for 2016-19 as informed by the Trust Quality and Safety Committee’s own review of effectiveness and


324 November 2015. This event included a review of our current position against this year’s priorities and a discussion on the quality priorities for the forthcoming year. Results from the discussions on the day show that some areas of improvement that we have focused on during 2015/16 still need further work which includes improving the experience of people requiring medicines in the inpatient and outpatient settings and ensuring the safety of vulnerable and older people, particularly in relation to discharge management and for those with disabilities.

patients’ needs. Introduction of nutritional link nurses with delivery of training and resource folders for the wards. In addition the Trust held a week long campaign during Nutrition and Hydration week to focus patients, visitors and staff on the importance of nutrition and hydration.

Quality priorities for improvement in 2016/17

In this section of the report, we tell you about the areas for improvement for the next year in relation to the quality of our services and how we intend to assess them. To develop these priorities, the Trust held an engagement exercise with key stakeholders (Foundation Trust members, HealthWatch, governors, local voluntary organisations) on

> We have seen improvements in the key indicators as part of our patient safety priorities and these include:

– A 2% improvement in medication safety incident reporting during 2015/16 and the employment of a Medication Safety Officer to drive forward our improvement campaign

– There has been a small reduction in inpatient falls and hospital acquired pressure ulcers; we have not achieved the stretching targets that we set ourselves for the year

– Improvements in the care for people with dementia (outlined later in report)

– Improvement in staff awareness of malnutrition in hospital and completion of nutritional risk assessments with staff taking specific actions to address

Respondent Category Quality Priority Topic 2016/17

Patient Safety

Staff

Healthwatch

Governors and Foundation Trust (FT) members

• NEWS compliance – testing the knowledge and understanding of staff

• Improve recruitment and retain staff

• Improved communication about medications and the needs of individual patients

• Reduce patient harms, such as patient falls

Clinical Effectiveness

Staff

Healthwatch

Governors and FT members

• Ensure integrated care systems and collaboration

• Need to have electronic records

• Care of the elderly not well co-ordinated and communication can be ineffective

• Delayed discharges - prioritise patients for discharge

• Processes for patients with mental health issues need improving

Patient Experience

Staff

Healthwatch

Governors & FT members

• Improved communication and staff attitude, ensuring robust CARES programme - delivery of customer care training

• Lack of positive response from staff to suggestions made by patients

• All patients must receive individualised care – thorough assessment of needs

• Sensitivity with giving information that is tailored to individual patients

• Keeping people updated in A&E

• There is no loop system for hard of hearing patients. Staff have to raise their voices and the environment can be noisy

• Visual information often not suitable for people with eyesight problems.

• Clinic organisation not good – too many cancellations

• Patients waiting for TTAs. Better co-ordination with the Pharmacy department.


observations. Timely interpretation and escalation of recognised deterioration is of crucial importance in minimising the likelihood of serious and adverse events including cardiac arrest and death.

NEWS audits conducted during 2015/16 have shown that staff are not fully compliant with our Trust NEWS policy with regard to fully documenting the evidence of escalation and the review of the acutely unwell patient. There needs to be increased training in this area and there also needs to be a better understanding of when it is appropriate to make physiological parameter changes dependent on the patient’s condition. This was also a safety priority identified by our stakeholders at the Quality Report consultation event. How are we doing so far?Our NEWS compliance audit scores have not demonstrated significant improvement during this past year. In addition, patient safety incidents concerning NEWS compliance continue to be reported via our incident reporting system. There have also been two serious incidents concerning NEWS and the escalation of the deteriorating patient that have been investigated using detailed Root Cause Analysis investigation by a multi-professional panel. Inadequate

2016/17. These have been identified as falling under the three domains of safety, clinical effectiveness and patient experience as follows:

PRIORITY 1

Achieving NEWS (National Early Warning Score) compliance to support early escalation of the deteriorating patient

Why is this one of our priorities?Maintaining patient safety is a key priority for the Trust. The National Early Warning Score (NEWS) is a simple physiological scoring system that can be calculated at the patient’s bedside, using agreed parameters which are measured in all patients who attend hospital. It alerts health care staff to abnormal physiological parameters and triggers an escalation of care and review of the patient. Clinical deterioration can occur at any stage of a patient’s illness. There will be certain periods when a patient is more vulnerable to deterioration for example, the onset of illness, during surgical or medical interventions and during recovery from critical illness. Patients on general adult wards and emergency departments who are at risk of deteriorating may be identified before a serious adverse event by changes in their physiological

It was recognised that this work will continue outside of the priorities identified in this year’s Quality Report as there are key working groups that continue to focus on these improvement areas further. An outline of the key results from the consultation is included in the table below.

Quality Report 2015/16 Consultation

In addition, the Trust triangulated data from several sources to identify themes and recurring trends. The Trust has engaged with clinical and management staff via divisional governance board meetings and divisional reviews to establish priorities. During the last year there has continued to be active engagement with our local Healthwatch including its members on several of our Trust working groups. The Trust has also met with Healthwatch on a quarterly basis to review quality and patient safety data and progress on the quality report priorities. This engagement has proved invaluable in being able to hear the feedback that Healthwatch receives from people with which it engages.

The Board has considered all of the suggestions put forward and the review of data and the priorities below have been recommended for inclusion in the Quality Report for

No. Priority Safety Clinical Effectiveness

Patient Experience

1 Achieving NEWS compliance to support early escalation of the deteriorating patient

✓ ✓ N/A

2 Achieving improvement in relation to seven day working priorities

✓ ✓ ✓

3 Delivering compassionate care and improving communication N/A N/A ✓

4 Safer staffing – improved recruitment and retention to ensure delivery of safe care. ✓ ✓ ✓


3most impact on reducing weekend mortality:

> Standard 2: Time to First Consultant Review

> Standard 5: Access to Diagnostics

> Standard 6: Access to Consultant Directed Interventions

> Standard 8: On-going Review (planned for 2016/17)

North West London (NWL) as a sector accepted the opportunity to be a national First Wave Delivery Site for the new seven day services programme. As part of this programme, all acute trusts have agreed to achieve delivery of four prioritised Clinical Standards by April 2017.

NHS England, Monitor & the Trust Development Authority wrote to all acute trusts in England to ask that they establish a 2015/16 baseline for four of the 10 Clinical Standards for seven day service. The four standards were selected with the Academy of Medical Royal Colleges as having the

NEWS compliance has now been put onto the Trust’s corporate risk register. Identifying improvement in NEWS compliance to support the care of the deteriorating patient as one of our quality priorities will assist in driving up performance to ensure our patients receive safer care.

Our aims for 2016/17 are:All aspects of the NEWS process and the outcome measures need to be addressed. This includes education to all healthcare professionals, policy review and continuing audit.

Key objectives:

> Review the NEWS education programme – this includes revisiting what is taught, how it is taught and by whom. Explicit learning outcomes to be made transparent and to ensure that evaluation of education reflects learning outcomes

> Continue NEWS audits regarding completion of NEWS charts and also compliance with escalation policy via monthly 24 hour snapshot NEWS audits. To aim to achieve greater than 90% in all audited criteria as a minimum

> Reduction in the number of patient safety incident forms completed of moderate severity or higher.

PRIORITY 2

Achieving improvement in relation to seven day working priorities

Why is this one of our priorities?NHS England has committed to offering a much more patient-focused service moving towards routine NHS services being made available seven days a week. Evidence shows that the limited availability of some hospital services at weekends can have a detrimental impact on outcomes for patients, including raising the risk of mortality.


No. Item Progress

1.

2.

3.

2015/2016 CQUIN standard 3 – Multi professional team review for 95% of patients in Medicine and Surgery

2015/2016 CQUIN standard 4 – Shift handovers with 95% to meet national standards in Medicine and Surgery

2015/2016 CQUIN standard 5 – 7 day consultant presence in radiology, quarter 4 report showing 95% of all urgent tests and 95% of all non-urgent tests are reported within the London and national standards time frame

The Trust has achieved 70% of targets for working towards providing seven day services. There is still room for further improvement in some areas for example, faster reporting of diagnostic test results and multidisciplinary assessment for patients admitted in the evening.

4. 2015/2016 contract – standard 2 – Time to first consultant review

THHFT has participated in a repeat national audit to establish baseline results and is yet to be analysed and published. 15/16 saw physicians being resident on call at weekends, and A&E consultants working extended hours seven days a week.

5. Better Care Fund (BCF) – standard 9 – Transfer to Community, Primary and Social Care

A multi provider action plan has been agreed – examples of some of the achievements include management of complex wound care is now available for elective patients in the community, the establishment of an integrated discharge team in pilot form based in the Acute Medical Unit.

Discharge Improvement (Standard 9)

> Single NWL-wide discharge assessment form

> Current state overview of each Clinical Commissioning Group (CCG) Individual CCG Implementation Plans/ Roadmaps

> Delivery of workshops required as part of the implementation roadmap

> Single Points of Access in place for each CCG that include the minimum required services and that accept and use the common NWL assessment form.

THHFT has appointed a lead Clinician to help achieve the key milestones outlined above.

Radiology and Diagnostics (Standard 5)

> Imaging inpatients within 24 hours of request

> Timely reporting compliant with national standards

> Practical and functional pathways for radiological diagnostics and interventions agreed

> Formalised network across NWL for specialised reporting.

Interventions (Standard 6)

> Robust pathways for inpatient access to interventions in place 24 hours a day, 7 days a week (critical care, interventional radiology, interventional endoscopy, emergency general surgery, renal replacement therapy, urgent radiotherapy, thrombolysis, Percutaneous Coronary Intervention (PCI – coronary angioplasty) and cardiac pacing.

How are we doing so far?

Our aims for 2015/16 are shown in the table below.

Our aims for 2016/17, in addition to embedding and building on the achievements from 2015/16, are:

Model of Care required to deliver Standards 2 & 8

> Define clinical outcomes

> Develop model of care to meet clinical outcomes and determine consultant requirement

> Test proposed model of care against current clinical capacity and evidence base

> Plan delivery of agreed model of care.


3

In addition, the Trust participates in the annual national patient survey programme. The CQC 2015 survey report is still awaited; this will be published in June 2016 and will be available via the Trust public website. The Friends and Family Test has also been fully rolled out to all patient areas with valuable feedback being provided in the commentary from patients and their families. During 2015/16 over 25,000 patients took up this opportunity and answered the FFT questionnaire.

Results from our local surveys and the FFT can be seen in Part 3 of this report; also included are some of the themes from the feedback which include elements of communication and what we have done to improve on this.

There will be an increased focus on staff undertaking customer care training in 2016/17 to ensure more of our staff are better equipped to enhance communication with our patients and their families.

The Trust has continued to deliver training for our staff on improving the patient experience of care via a Customer Care training programme. To date 47% of our staff have attended this training. The elements of compassionate care and communication continue to be monitored via our local patient experience survey and the aim will be to realise improvement in this area.

Initiatives introduced include patient stories being presented at every Trust Board meeting, a refreshed Experience and Engagement Group involving public governors, Healthwatch Hillingdon and representation from the voluntary sector and improvements made to the availability of written information for patients.

With regard to improving communication and accessibility to information all organisations that provide NHS or adult social care must implement the Accessible Information Standard by law with effect from 31st July 2016. The aim of the Accessible Information Standard is to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand and any communication support that they need. This includes making sure that people get information in different formats if they need it, for example in large print, braille, easy read or via email. The standard also includes providing support from a British Sign Language (BSL) interpreter, deaf-blind manual interpreter or an advocate.

PRIORITY 3

Delivering compassionate care and improving communication

Why is this one of our priorities?We have received feedback from patients and their families that this is an area that we need to continue to focus on. Listening to feedback, as part of our communication with patients, enables our staff to gain a real insight into the patient’s experience of care and make further improvements. Ensuring staff are responsive to patients needs and communicate effectively is a key priority.

How are we doing so far? The CQC found during their inspection in October 2014 that patients reported that they felt well cared for and the Trust was given a ‘good’ rating for the caring domain as part of their assessment process.

We have implemented John’s Campaign, a national initiative to enable carers to support their loved ones outside of visiting times in accordance with their wishes. This provides for a better patient experience and can alleviate patient anxiety during a hospital stay. Key staff from different professional groups have undertaken the Alzheimers’ Society Foundation Certificate in Dementia Awareness which focuses on providing patient-centred care.

There will be an increased focus on staff undertaking customer care training in 2016/17 to ensure more of our staff are better equipped to enhance communication with our patients and their families.


Therapies have also successfully piloted a buddy scheme to support new joiners and rotational positions for staff have been expanded across dietetics, OT and PT. Rotations with other Trusts have been explored although not yet established. Advanced roles have been developed with an additional Extended Scope Physiotherapist trained to work alongside the orthopaedic team.

For nurse staffing there has been a continuous drive to reduce nurse vacancies throughout the year with a rolling programme of recruitment days at the Trust, attendance at university job fairs and targeted European campaigns. The recruitment team has worked closely with the medical and surgical divisions to implement bespoke recruitment plans for areas with specialised needs. We have however continued to have staffing gaps and we have relied on agency staff to ensure our additional wards (open to meet the demand for inpatient beds) are safely staffed. Where agency staff are utilised our recruitment teams ensure that approved agencies are used and that all agency nurses have had the appropriate checks and have the appropriate safety training. All agency staff are monitored by the wards for their competences including their verbal communication skills, should any short falls be identified then it would be reported to the Temporary Staffing Manager for investigation and the agency nurse would be suspended from working at the Trust.

Enhanced nurse induction programmes have been developed to support the newly qualified nursing staff that we have been able to recruit and those staff recruited from overseas. Literacy and numeracy skills are tested alongside spoken English and language skills.

Trust needs to agree a more effective and robust recruitment and retention strategy to meet these challenges and to be the employer of choice for staff. We also need to reduce our vacancies in these staff groups and our reliance on agency staffing.

We also want to ensure that staff appointed at the Trust are recruited to our values and deliver safe and compassionate care to our patients. This is a priority as it assists with staff morale and it ensures a higher quality of care. It also improves retention with regard to a better staff experience of their work environment and the teams they work within. This was a safety priority identified by our stakeholders at the Quality Report consultation event.

How are we doing so far? The Medical Staffing Department are currently working with the surgical division providing information on vacancies and examining new ways of working. Further work is being taken forward in 2016/17 with the other clinical divisions on planning recruitment to their outstanding vacancies.

For AHPs, numerous initiatives have already been introduced. Some of these include promoting our hospitals at University Open Days and via recruitment flyers for use at local events. Attendance at Careers Fairs has led to candidates applying for roles, and being interviewed for posts. In Occupational Therapy (OT) and Physiotherapy (PT), graduate mailing lists have been compiled to create personal links with potential candidates. Services have continued to take AHP students as many of our AHPs have been attracted to work here having been with us on clinical placement.

Our aims for 2016/17 are:

> To achieve >96% satisfaction in the Friends and Family Test survey by March 2017.

> Realise a 5% reduction in complaints related to key themes including communication and staff attitude by March 2017.

> Improvement in national patient survey metrics for areas related to compassionate care and communication – target 90% by March 2017.

> Patients delayed by more than 20 mins for an outpatient appointment will be updated of the waiting times and informed of the reason for delay - target 80% by March 2017.

> The Trust is currently working towards implementing the Accessible Information Standard by reviewing current processes and undertaking a gap analysis to fully deliver the standard in 2016/17.

PRIORITY 4

Safer staffing – improved recruitment and retention to ensure delivery of safe care

Why is this one of our priorities? We need to ensure that we have safe staffing levels for medical, nursing and allied health professional (AHP) staff groups. This allows for improved continuity of care, effective communication and improved quality and safety of care for our patients. There are significant recruitment challenges with these staff groups across London and nationally. The


3

Medical Staffing

> To have a Medical Locums bank in place where gaps can be filled with our own Trust doctors to reduce the need for agency workers and be within the caps for agency usage – aim to achieve a phased launch by July 2016. Booking staff currently being recruited

> To recruit to the outstanding vacancies once the divisions have developed their recruitment plan and shared this with Medical Staffing – aim to achieve this by end of May 2016.

Our quality priorities will

be monitored by clinical

and management teams

through their divisional

performance reviews and

via reports to the relevant

sub-Board Committee.

The results will also be

published in the 2016/17

Trust Annual Report.

Allied Health Professionals

> A workforce review will be completed within sonography and radiographers will complete sonography training - aim to achieve the review by end of August 2016 and two trainee sonographers to complete the course by September 2016

> A shared competency framework will be established for OTs and PTs on the acute wards – aim to achieve this by end of August 2016

> A development programme to support Band 5 OTs and PTs to move to Band 6 posts within the Trust – aim to achieve this by end of October 2016

> Pharmacy will be a pilot for central recruitment of pre-registration pharmacists which is envisaged to improve recruitment. We will be participating in the HEE centralised recruitment for the intake in August 2017 with interviews for this being held in September 2016 with a recruitment fair for the candidates in July 2016.

Nurse Staffing

> To significantly reduce vacancy levels in specific clinical areas: A&E, the Acute Medical Unit and Fleming Ward (surgery and gynaecology) – aim to achieve this by end of July 2016

> To develop a peripatetic (flexible, responsive and targeting gaps) nursing team to respond to additional short-notice staffing requirements (planning meeting – 23 June)

> To embed a proactive recruitment programme based on anticipated demand surge – aim to achieve recruitment programme by end of June 2016. Planning for international recruitment to the Philippines by end of July 2016

> To achieve a vacancy rate for nursing of no more than 8% in line with the Trust target and a turnover rate no greater than 10%

> To continue to develop and implement retention initiatives (planning meeting – 23 June).

Our aims for 2016/17 are:


participated in 95% of national clinical audits and 100% of national confidential enquiries of the national clinical audits and confidential enquiries which it was eligible to participate in.

The national clinical audits and national confidential enquiries that The Hillingdon Hospitals NHS Foundation Trust was eligible to participate in during 2015/16, and for which data collection was completed during 2015/16, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

Hillingdon Hospitals NHS Foundation Trust for 2015/16.

Participation in clinical audit

National audits

During 2015/16, 37 national clinical audits and three national confidential enquiries covered relevant health services that The Hillingdon Hospitals NHS Foundation Trust provides.

During that period The Hillingdon Hospitals NHS Foundation Trust

Provision of NHS Services

During 2015/16 The Hillingdon Hospitals NHS Foundation Trust provided medicine, surgery, clinical support services and women’s and children’s NHS services. The Hillingdon Hospitals NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by these relevant health services reviewed in 2015/16 represents 100% of the total income generated from the provision of the relevant health services by the

2.2 Formal statements of assurance from the Board

Information for our regulators

Our regulators need to understand how we are working to improve quality so the following

pages include specific messages they have asked us to provide:

Audit Participated Cases submitted

Acute Myocardial Infarction Yes 100%

Bowel Cancer Audit Programme Yes 100%

Adult Critical Care Case Mix Programme Yes 50%

National Paediatric Diabetes Audit (Royal College of Paediatric and Child Health)

Yes 100%

Elective Surgery (National Patient Reported Outcome Measures (PROMS) Programme)

Yes Hip – 255 Knee – 377Hernia – 43Varicose Veins - 26

Emergency Use of Oxygen Yes 100%

Falls and Fragility Fractures Audit Programme National Hip Fracture Database

Yes 100%

Falls and Fragility Fractures Audit Programme National Inpatient Falls Audit

Yes 100%

Falls and Fragility Fractures Audit Programme (FFFAP): Fracture Liaison Service Database

Yes Audit launched in January 2016. Trust has registered to participate for data collection commencing March 2016

Inflammatory Bowel Disease (Biologic Audit) Yes 100%

Major Trauma Audit Yes 31%

National Audit of Intermediate Care N/A Service not in place to enable Trust to submit to this audit



National Cardiac Arrest Audit Yes 100%

National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme (pulmonary rehabilitation)

N/A

National Comparative Audit of Blood Transfusion: Audit of Transfusion in Children and Adults with Sickle Cell Disease

Yes 100%

National Comparative Audit of Blood Transfusion: Audit of Patient Blood Management in Scheduled Surgery

Yes 100%

National Comparative Audit of Blood Transfusion: Audit of Lower Gastro-intestinal Bleeding and the Use of Blood

Yes 100%

National Complicated Diverticulitis Audit Yes 100%

National Adult Diabetes Audit : National Foot Ulcer audit

Yes Trust commenced participation in July 2016

National Adult Diabetes Audit : National In-patient Diabetes Audit

Yes 100%

National Adult Diabetes Audit : National Pregnancy in Diabetes Audit

Yes 100%

National Adult Diabetes Audit : Out-patient Management

No IT requirements are under review to enable future participation.

Mortality and Morbidity in Diabetes Yes 100%

National Emergency Laparotomy Audit (NELA)

Yes 84 cases submitted

National Heart Failure Audit Yes 72%

National Joint Registry Yes Hillingdon – 56%Mount Vernon – 88%

National Lung Cancer Audit Yes 100%

National Ophthalmology Audit Yes Audit commenced in September 2015, Trust is participating

National Prostate Cancer Audit Yes 100%

National Intensive and Special Care (NNAP) Yes 100%

National Oesophago-gastric Cancer Audit Yes 100%

Paediatric Asthma Yes 100%

National Audit of VTE risk in lower limb immobilisation (College of Emergency Medicine)

Yes 100%

National Audit of Vital signs in children (College of Emergency Medicine)

Yes 100%

National Audit of procedural sedation in adults (College of Emergency Medicine)

Yes 100%



Rheumatoid and early inflammatory arthritis No Medical Director and Divisional Director for Medicine have agreed with our Rheumatology team that participation in this audit would not contribute significantly to the quality of the service provided by the Trust.

Sentinel Stroke National Audit Programme Yes 100%

UK Parkinson’s Audit Yes 100%

Head and Neck Oncology (Data for Head and Neck Oncologists)

N/A This is N/A to the Trust - for 2015/16 this audit was only applicable to Trusts who have data published as part of the Consultant Outcome Publication process.

Clinical Outcome Review Programmes

MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK

Yes 100%

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Acute Pancreatitis

Yes 100%

NCEPOD Sepsis Yes 50%

The reports of 13 national clinical audits were reviewed by the provider in 2015/16 and The Hillingdon Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.

Audit Actions

National Pregnancy in Diabetes Audit A masterclass on diabetes in pregnancy has been given to local GPs.Shared GP guidelines have been updated and are available on the Extranet. Local hospital diabetes in pregnancy guidelines are currently being updated.

BTS Adult Community Acquired Pneumonia

The Trust has an antibiotic guideline app. To support scoring the severity of pneumonia, the CURB score, has been incorporated into the antibiotic guidelines app.

National Cardiac Arrest Audit The Trust is regularly in line with NCAA National average for cardiac arrest standards. On one occasion the hospital was identified as having higher cardiac arrests at the weekend, a review of all cases was undertaken. This was completed by the Lead Resuscitation Officer – no issues were identified.

National Emergency Laparotomy Audit (NELA)

A local protocol and pathway is in development to support formalising a consultant-delivered service for emergency laparotomy patients. This will cover cross disciplinary roles between surgeons, anaesthetists, radiological and laboratory services and theatre and critical care staff

National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme

To help ensure COPD patients receive specialist respiratory review a COPD hotline (mobile number staffed during working hours) has been put in place since Jan 2016. This has been distributed to all appropriate clinical areas including A&E.To increase the number of patients offered specialist respiratory follow up on discharge, an Integrated care COPD clinic set up as of Feb 2016. All patients seen by the COPD outreach team are offered an appointment. Guidelines for clinic referrals to be circulated to acute medical consultants for all other patients.


Audit Actions

Initial management of the fitting child in the Emergency Department

This audit highlighted that blood glucose is not always measured or documented in the fitting child. Current guidelines are being reviewed for update. Following this education will take place.

Mental health in the Emergency Department

Discussion to take place with Central North West London NHS Foundation Trust to review documentation regarding risk assessment and mental state examination.

Assessing for cognitive impairment in older people in the Emergency Department

A&E leads are working with Trust Dementia leads to review what assessment proforma is to be used in the Emergency Department.

National Paediatric Diabetes Audit Diabetes poor control action board and meetings in place. Paediatric diabetes team have all been trained as a team in health coaching to encourage self-management. A transitional service survey is underway. A flow chart for management of high blood pressure and microalbuminuria is in development.

National Audit of Mortality and Morbidity in Diabetes

For nurse training around diabetes management, weekly walk-in sessions have been put in place, topics include management of high blood sugar (hyperglycaemia) and low blood sugar (hypoglycaemia). In addition to this insulin education training is being provided to junior doctors.The blood glucose and hypoglycaemia management charts are currently being revised so that both the charts can be incorporated into a single chart for ease of use by staff.All diabetes protocols are widely available on the hospital intranet and are promoted by the diabetes specialist team.

National Inpatient Falls Audit Following this audit we have continued our bi-monthly Falls Steering group, with executive lead support, to oversee the Trust wide strategy for a reduction in falls. A Falls Working Group is being set up within each division to report back to the Steering Group and share local learning. A quality improvement project dedicated to the assessment of patients having had a fall and their aftercare is currently ongoing to standardise and streamline our approach.

National BTS Emergency Use of Oxygen Audit

The Trust is looking at training needs and documentation improvements. A specific oxygen monitoring chart is being considered to be used alongside the existing section within the prescription chart.

NCEPOD ‘Just Say Sepsis’ An inpatient Sepsis Lead is being identified to work alongside the consultant lead in A&E. The sepsis proforma and guidelines will be reviewed and re-published.


The reports of 82 local clinical audits were reviewed by the provider in 2015/16 and examples of The Hillingdon Hospitals NHS Foundation Trust actions to improve the quality of healthcare provided are as follows:

Audit Actions

Audit of details regarding Acute Kidney Injury (AKI) on Discharge Summaries to GPs

This audit is against the national standard for patients with a confirmed diagnosis of AK which is that the hospital discharge letter to the GP should contain advice regarding the stage of AKI along with any recommendations for repeat blood tests.During 2015/16 the hospitals’ Consultant Lead for AKI has been undertaking the audit and providing targeted clinical training and awareness sessions to support improvement where required. The Trust has also included mandatory questions in the electronic discharge summary system to prompt doctors to include appropriate information.

Clinical Record Keeping Standards As an improvement in identifying authors of specific entries within clinical notes, stamps have been provided to doctors and nurses To raise awareness of Trust standards for record keeping, a poster has been developed and has been made available within the hospital. We are going to agree the five main areas for improvement as key indicators for monitoring, these will include documenting date, documenting time, identifying who has written in the notes/use of the name stamp, documenting bleep number.

Safe Sedation at Hillingdon Hospital Safe Sedation guidelines have been updated to include sedation in Emergency Department, Endoscopy and Radiology. A pre-procedure checklist is also being developed for use in areas providing sedation.

Post-operative Bowel Monitoring Bowel surgery is part of an Enhanced Recovery Programme (ERP). To support improved documentation of post-operative bowel monitoring the ERP proforma has been updated to include daily post-operative documentation of bowel actions.

Timing of discharges from ITU and audit of the ITU handback protocol and discharge summary

This audit has resulted in the improvement in the level of detail and the quality of medical and nursing handover when a patient is discharged from ITU to a ward. Following implementation of the improved discharge document, a re-audit has shown a significant increase in the audit results, including improved documentation of: ceilings of care, nutritional needs, physiotherapy and rehabilitation needs, psychological and emotional needs, communication, speech and language needs. Overall, there has been positive feedback from staff using the revised discharge summary.

Compliance with the Recommendations on Monitoring following Epidural Catheter Removal

Teaching on the Management of Leg Weakness and Motor Block with Epidural or Spinal Analgesia guideline is included on the Acute Pain study days which are held regularly 3 or 4 times a year. The Acute Pain nurses also educate ward staff during their daily Acute Pain rounds on the Surgical wards and ITU.The Consultant Lead for Acute Pain has provided study sessions to the junior doctors as part of their Foundation Programme training.

Bedside Blood Transfusion Practice The Trust Transfusion Practitioner has undertaken targeted awareness and training on the transfusion process and has updated the mandatory training to focus on the areas identified for improvement within this audit. To continue to drive improvement in standards, the Transfusion Practitioner has increased visibility on the wards and undertakes snapshot checks on transfusion charts - real time feedback is given to the nurse in charge of the shift.


Audit Actions

Delirium New delirium assessment form is being designed and agreed with clinical leads for dementia, this will then be issued for use in the hospital. Additional delirium awareness training will be provided to support implementation of the revised form.

WHO Checklist A Trust-wide WHO Checklist Policy is going to be produced. This will include all areas of the hospital that use safety checklists (as well as theatres) for example, interventional radiology.

Dementia Carers Survey The dementia cares survey is part of a larger project to improve dementia care in the Trust. Actions taken to make improvements included Dementia Resource folders are in place within the Trust.‘John’s campaign’ was launched in the Trust. The survey has been amended to include the ward, so the Dementia Specialist Nurse where required, can target awareness and training to raise standards.

Do Not Actively Resuscitate (DNACPR) The hospital Resuscitation Officers, undertake monthly DNACPR snapshot audits looking at completion of the forms, this takes place alongside an annual DNACPR standards audit. Actions taken include more emphasis on DNACPR in existing life support training and on induction. Awareness raising, for nursing staff, to support meeting DNACPR standards.

Paediatric CAS Card Safeguarding Audit - A&E

To improve awareness of the safeguarding checklist, and the requirement to refer to the Health Visiting Team if the child has had more than three attendances in six months, communication has taken place within A&E. This has also been added to existing training sessions to improve this standard.

Commitment to research as a driver for improving the quality of care and patient experience

The number of patients receiving relevant NHS health services provided by The Hillingdon Hospitals NHS Foundation Trust in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee was 444 patients.

The Hillingdon Hospitals NHS Foundation Trust has a good research track record for a hospital of its size.Our main research activity is recruiting patients into high quality National Institute for Health Research (NIHR) portfolio adopted multi-centre trials.We participate in commercial research funded by the pharmaceutical industry and non-commercial research which is funded from the Department of Health via the NIHR North West London (NWL)

Clinical Research Network (CRN).In 2015/16 we received £380,528 from the NWL CRN for this work. The funding enables the Trust to employ research nurses and data managers to support the clinicians in this work.

Our Strategic Aims for 2014 to 2019 are:

> To expand the number of patients recruited into high quality clinical trials

> To expand the number of specialties that are actively participating in clinical trials

> To adapt to the changing national and regional organisation of clinical research and funding.

This has enabled us to offer a greater number of patients, from different clinical areas, the opportunity to participate in research. In 2015/16 we opened our first research study in Critical Care. We also employed our first Research Midwife and we now

have a number of studies running in our Maternity Unit.

Participation in clinical research demonstrates The Hillingdon Hospitals NHS Foundation Trust’s commitment to improving the quality of care we offer and to making our contribution to the nation’s wider health improvement. This also allows clinical staff to stay abreast of the latest treatment possibilities giving patients access to new treatments that they otherwise would not have.

The Trust has an extensive research portfolio with a balance of observational and treatment trials across many clinical areas including cancer, stroke, haematology, paediatrics, and many of the general medicine and surgical specialities. In 2016/17 we plan to become more research active in musculoskeletal disorders and Diabetes.

We also support PhD and Masters students from the local universities


led panel investigations (these are usually formed for Never Event and unexpected death cases).There were two Grade 3 and two Grade 4 pressure ulcers (these involve partial or full thickness skin loss and damage to the deepest layer of skin) reported during the period.

Protecting patients from avoidable harm is something to which there is universal agreement and the Trust has clearly defined processes and procedures to follow to help to reduce the risk of these events occurring. However where a serious incident does occur lessons need to be learnt through a process of root cause analysis investigation and actions taken to prevent reoccurrence. Some of the learning from these Serious Incidents during 2015/16 includes the following:

with the national Serious Incident (SI) reporting framework and the categorisation of SI cases. Seven of these cases were subsequently de-escalated as not meeting the SI criteria on further investigation. Two ‘Never Events’ (both misplaced nasogastric tubes) were reported, one in February and one in March 2016. These investigations have been completed and reported to the Trust Board. The Board will monitor the action plans through to completion.Serious Incident cases include unexpected admissions to neonatal care, grade 3 or 4 pressure ulcers and categories such as unexpected death, sub-optimal care of the deteriorating patient, delayed diagnosis, drug incidents and surgical error. Nine of these cases have been Non-Executive/Executive Director

giving them access to our patients and staff for their projects. In 2015/16 we approved and supported eight such university student projects. These are due for completion during 2016/17.

During 2015/16 we ad approximately 65 NIHR Portfolio Studies open or in follow-up and we recruited 480 patients into 39 trials. All of our research activity is scrutinised for quality and compliance to the standards expected by the Research Governance Framework. In addition we work to comply with the Department of Health NIHR objectives.

Lessons learned from Serious Incidents

During 2015/16, the Trust reported 35 ‘Serious Incidents’ in accordance

Area Division Summary

Effective communication

Maternity Communication in both verbal and written format should be effective. This refers to communication between staff, across the ward and between organisations.

Record keeping Maternity Documentation completed in retrospect, must be marked as such in the patient’s notes. It is also best practice to complete records immediately following the event.

Following best practice and guidelines

Maternity Staff must follow best practice guidelines at all times, for consent, maternal observations, vaginal examination and management of post postpartum haemorrhage.

Clinical Leadership Maternity Leadership of the emergency procedure must be clear and concise.

Patient pathway of care

Maternity It is essential that women are moved from Maternity Triage within an appropriate timeframe to the relevant care setting.

Translation services

Maternity Necessity to provide an appropriately trained translator to minimise disruption to the patient’s diagnosis and treatment pathway

Early warning scoring systems

Maternity MEWS charts must be routinely used by all staff when women are admitted to Maternity Triage.

Blood sampling Maternity When haemolysed blood results are recorded, the full clinical picture should be taken into account and reviewed as if it was an abnormal result.

Clinical handover Maternity Current structure of patient handover needs to be improved

Review of diagnostic imaging

Medicine There should be a process in place that ensures the requesting consultant, or an appropriate member of their team, review the final radiology report prior to discharging a patient.



Escalation of diagnostic findings

Medicine There should be consistent pathways and processes in place to communicate and escalate suspected cancer findings in diagnostic reporting.

Identification of patients

Medicine When requesting a diagnostic test via the Trust’s electronic system staff must always search using the patient’s hospital/NHS number.

Triangulating patient identifiers

Medicine Information on a request number should be triangulated using the patient’s surname, date of birth, hospital or NHS number.

Labelling of samples

Medicine Self-adhesive addressograph labels which detail the patient’s demographics should be used when sending samples for processing to histopathology. Handwritten labels should not be accepted from departments within the Trust.

Manual handling requirements

Medicine Greater consideration should be given to meeting the care/moving and handling requirements of all obese/bariatric patients, where the patient has suffered a stroke these needs will be amplified.

Pressure ulcer prevention

Medicine The procedure for recording pre-existing tissue damage, assessing risk, developing a management plan, and escalating concerns should be reviewed; tissue viability needs should be reviewed by the MDT as an intrinsic component of the patient’s health status.


Medicine Access to specialist expertise in tissue viability and manual handling should be reviewed and sourced.


Medicine Information about the range of technical equipment available to support obese or bariatric stroke patients should be readily available on the ward.

Staffing Medicine Recognising the impact on the safety and quality of care for all patients if patients with specific needs are accepted without having the required equipment and/or staffing level.

Escalation within the Resus room in A&E

Medicine There needs to be clear definition of the roles and responsibilities of the nurse in charge of Resus.

NEWS compliance Medicine As an addition to the “next steps” implementing NEWS into the hospital, designate a clinical governance meeting to embed a framework for reviewing NEWS policy, practice and effectiveness.

Care of the patient with Sepsis

Medicine Identify a Trust-wide Sepsis lead to champion Sepsis management and compliance.

ITU Referral process

Surgery The ITU referral pathway should be reviewed and disseminated Trust-wide.

Communication with families

Surgery Review the Trust’s process of communication with family and friends.

ITU team Surgery Review current ITU nursing roles and responsibilities regarding handover practices.

Medication history Surgery Medication records are to be ratified as soon as possible following a patient’s admission to hospital, including contact with the GP.

Omitted medicines

Surgery Nursing staff need to record in the prescription chart the reason why prescribed medication has been omitted.



Record keeping Surgery Medical staff should document reasons for prescription changes in the patient’s record.

Nutritional assessments

Surgery Nutritional assessments need to be completed and clear clarification made on recommended oral intake of solids and fluids.

Diabetic management

Surgery Early referral of eligible patients for specialist diabetes advice and management is vital for safe glucose management.

Patient transfers Surgery Evening patient transfers to other wards to be arranged and completed before the day shift nurses finish duty.

Resuscitation procedure

Surgery If in doubt of the resuscitation status of a patient, staff must put the cardiac arrest call out and start basic life support.

Patient care and management

Surgery The importance of team working, clinical handover and effective leadership in holistic patient care and management.

Staffing Surgery Agency staffing should be kept to a minimum to support continuity of care and high quality care.

Clinical pathway Surgery Standardised post-operative care of the patient having areversal of ileostomy is required.

Prescription charts Surgery All drugs prescribed for inpatients should be written on a single inpatient drug chart.

Discharge communication

Surgery Clear communication is required with the patient and their family regarding discharge.

Referral pathways Surgery The Clinical Team who are referring to tertiary centres need to ensure that they follow the agreed referral process and make it clear when the referral is of an urgent nature.

Medical referrals Surgery There needs to be clarity on what constitutes a routine referral as opposed to an urgent, critical or life-threatening referral and the acceptable timeframe for these to happen.

Communication with patients

Surgery There should be a detailed, documented, discussion with patients about their diagnosis, the severity and what to do if symptoms worsen.

Support for patients

Surgery Clinicians should consider asking for a nurse to be part of the medical consultation to provide support to the patient when breaking bad news.

Patient letters Surgery The communication processes for dictating/sending referral letters should be reviewed and all letters should be uploaded to PAS and copies filed in the patient’s notes in a timely manner.

Review of imaging results

Radiology / Surgery Radiology and Surgical teams should jointly review contrast enema results before the decision for surgery is made.

Review of x-rays Radiology All routine x-rays to be examined holistically looking for anything else that may be present not just the reason for original request.

Patient symptoms Radiology The need to explore symptoms being described by the patient and not rely entirely on imaging.

Supervision of practice

Radiology Procedures undertaken by Radiology Registrars should be authorised by a consultant radiologist unless the Radiology Registrar is deemed competent to act without consultant input in specified procedures.


3Serious Incident and Never Event actions plans based on the learning from investigations are implemented and monitored via clinical divisional governance boards until fully completed. Director-led panel investigation reports and action plans are approved and reviewed by the Trust Board until fully completed. A recent audit conducted by the Trust’s internal auditor, Tiaa, gave ‘reasonable assurance’ on the processes and systems that are in place within the Trust to adequately learn from patient safety incidents. An action plan has been developed to ensure investigations are completed within acceptable timeframes and that the learning is shared more widely across the organisation.

As part of our duty in being open and honest with patients and their families, the findings from Serious Incident investigations are shared with them and information is provided on the learning and the actions that the Trust is taking forward to prevent reoccurrence.

Statutory Duty of Candour – Key recommendation from the Francis Inquiry

The Duty of Candour was passed by Parliament 6th November 2014 and took effect 27th November 2014. This places a requirement on providers of healthcare to be open with patients when things go wrong. Providers are required to establish the duty throughout their organisation ensuring honesty and transparency are the norm.

What is the Statutory Duty of Candour?

Where a notifiable safety incident has happened a health service organisation must – as soon as reasonably practicable:

> Notify the patient that a safety incident has happened and apologise

> Provide an account of all the facts known about the incident

> Advise the patient what further enquiries into the incident are appropriate

> Provide reasonable support to the patient

> Follow up in writing confirming the information and results of further enquiries and an apology

What is a ‘notifiable safety incident?’

Any unintended or unexpected incident that occurred in the organisation’s care that resulted in or appears to have resulted in:

> Death – directly related to the incident; or

> Severe harm, moderate harm or prolonged psychological harm (at least 28 days)

What does moderate harm mean?

Moderate harm means:

> Harm that requires a moderate increase in treatment, and

> Significant, but not permanent, harm;

Moderate increase in treatment means: an unplanned return to surgery, an unplanned re-admission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling treatment, or transfer to another treatment area (e.g. intensive care).

How is the Trust implementing the Duty of Candour?

The Trust has ensured that the Duty of Candour has been fully integrated into the Trust’s Incident Reporting and Being Open policies. Processes and systems have been implemented to ensure the legal and contractual requirements of the Duty are met. Staff awareness on the Duty has been raised via training and discussions at divisional meetings. Moderate and above severity incidents and action plans are monitored at divisional governance meetings and learning is shared via divisional governance forums and through team discussions. The Trust has put in place a robust monitoring system managed by the governance department staff with performance reports to divisional governance boards and the Clinical Governance Committee.

Goals agreed with our commissioners (CQUINs)

The key aim of the Commissioning for Quality and Innovation (CQUIN) framework is to secure improvements in the quality of services and better outcomes for patients, whilst also maintaining strong financial management. In 2015/16 there were ten acute CQUIN schemes agreed, of which five were national and five were locally derived with Hillingdon Clinical Commissioning Group. Four of the latter were regional schemes, mirrored in other hospitals across NW London. In 2015/16 we have achieved 85% of our acute CQUIN target, demonstrating a steady and consistently good performance. In 2014/15 we achieved 87.1%. Having either fully or partially achieved all of our CQUINs for 2015/16 will mean that


and £83,022 (100% of potential available income) for specialised CQUIN schemes. In the previous year (2014/15) the total income was £2,968,267 (87.1% of potential available income) for national and local schemes and £126,404 (95.9% of potential available income) for specialised commissioning.

In January 2015 TIAA (our internal auditors) conducted an audit to form an

innovation goals agreed between The Hillingdon Hospitals NHS Foundation Trust and any person or body we entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework.

Total CQUIN income for 2015/16, is expected to be £2,835,226 (85%) for national and local schemes

the quality of our services and the care that we deliver to our patients has improved.

The CQUIN framework enables commissioners to reward excellence, by linking a proportion of healthcare providers’ income to achievement. 2.5% of The Hillingdon Hospitals NHS Foundation Trust’s income in 2015/16 was conditional on achieving quality improvement and

CQUIN Targets 2015/16 Achievement Commentary

National Schemes

Improving communication with GPs for patients with kidney damage

Partial (30%) achievement

This is the first year that the Trust has been working on this CQUIN and results have improved significantly over time. By the end of the year the Trust was achieving 64% compliance with the national target.

Improving services for patients attending the ED with a sepsis


This is another first year CQUIN. The Trust is now consistently screening >90% of eligible emergency attendances for possible sepsis and, by the end of the year, administration of antibiotics in less than one hour was being achieved in >75% of cases.

Improving services for patients with dementia and their relatives/carers.


Developing IT systems to support integrated care

100% achievement

Reducing unnecessary admissions and A&E attendances

100% achievement

Regional Schemes

Reducing unnecessary follow-up appointments for outpatients

100% achievement

Working towards implementation of seven day services


The Trust has achieved 70% of targets for working towards providing seven day services.There is still room for further improvement in some areas for example, faster reporting of diagnostic test results and multidisciplinary assessment for patients admitted in the evening.

Improvingcommunication with GPs for patients who have long term conditions (COPD, Diabetes, Dementia, Heart Failure)

100% achievement

Timely referral to specialist cancer centres for patients with a positive diagnosis

100% achievement

Local Scheme

Providing ‘recovery at home’ for appropriate elderly patients (HomeSafe)

100% achievement


3of our services fully encompassed the review of systems and processes that our staff members follow, in addition to achieving key quality indicators and positive patient outcomes. As a result of the Trust actions against the Warning Notices the Trust increased compliance rates for staff training for all statutory and mandatory training and achieved >80% compliance as per Trust targets. The Trust also adopted cleaning targets in line with the National Specification for Cleaning standards (NSC) and met or exceeded the NSC targets across all clinical areas during 2015/16.The Trust undertook significant work to upgrade ventilation systems in the main theatres and it also completed overseas recruitment visits to attract nursing staff to the Trust whilst reducing the turnover of nurses.Our safeguarding children and adults arrangements and processes have also been strengthened.

The CQC re-visited the Trust on 5 and 7 May 2015 which resulted in:

> The de-escalation of the Warning Notices against regulations 10 and 12

> Changing the four red ‘inadequate’ ratings in the safety domain against A&E, Medicine, Surgery and Services for Children to ‘requires improvement’

> An overall rating for safety as ‘requires improvement’

> A requirement notice against Regulation 12: Safe Care and Treatment for Cleanliness and Infection Control.

The grid on the following page provides an overview of our ratings based on re-inspection of the Trust on 5 and 7 May 2016; the report was published on 7 August 2015.

The Trust was issued with formal warning notices against:

> Regulation 10 – Assessing and Monitoring the Quality of Service Provisions

> Regulation 12 – Cleanliness and Infection Control.

The Trust was also issued with five Compliance Notices against:

> Regulation 13 – Management of Medicines

> Regulation 15 – Safety and Suitability of Premises

> Regulation 16 – Safety, Availability and Suitability of Equipment

> Regulation 20 – Records

> Regulation 22 – Staffing.

The Board considered the overall rating (‘Requires Improvement’) to be fair. All of the recommendations were accepted and the Board was determined to make the necessary improvements. The concerns raised by the CQC in relation to the ‘systems to assess and monitor the quality of service provision with robust and effective processes to ensure minimal risk to patient safety’ were of immediate concern to the Board.

The findings provided a real impetus to ensure our assessment of the quality

opinion on the design and operation of controls over the Trust’s procedures for achieving CQUIN targets. They looked in detail at processes employed and governance arrangements as well as the systems used to provide evidence of achievement. Their overall assessment was of ‘substantial assurance’.

Further details of the agreed goals for 2016/17 are available electronically at: www.thh.nhs.uk.

Care Quality Commission registration

The Hillingdon Hospitals NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is that it is registered without conditions.

The Trust was inspected by the CQC in October 2014 as part of its planned and more detailed inspection regime. The final reports were published on 10 February 2015.The Trust was rated as ‘Requires Improvement’ overall. The Trust received a ‘good’ rating for the ‘caring’ domain across all of its services; staff were observed to be kind and had a caring and compassionate manner. Most of the people that the inspection team spoke with said that care was given in a kind and respectful way.


Our ratings for Hillingdon Hospital

Safe E�ective Caring Responsive Well-led Overall

Urgent and emergencyservices

Requiresimprovement Not rated Good Requires

improvementRequires

improvementRequires

improvement

Medical care Requiresimprovement

Requiresimprovement Good Requires

improvementRequires

improvementRequires

improvement

Surgery Requiresimprovement


improvementRequires

improvementRequires

improvement

Critical care Requiresimprovement


improvementRequires

improvementRequires

improvement

Maternityand gynaecology

Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Services for childrenand young people

Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

End of life care Requiresimprovement


improvementRequires

improvementRequires

improvement

Outpatients anddiagnostic imaging Good Not rated Good Requires

improvementRequires

improvementRequires

improvement

Overall Requiresimprovement


improvementRequires

improvementRequires

improvement

Our ratings for Mount Vernon Hospital


Minor injuries unit Requiresimprovement Not rated Good Requires

improvementRequires

improvementRequires

improvement

Medical care Requiresimprovement Good Good Requires

improvement Good Requiresimprovement

Surgery Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Outpatients anddiagnostic imaging Good Not rated Good Requires

improvementRequires

improvementRequires

improvement

Overall Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Overview of ratings

7 The Hillingdon Hospitals NHS Foundation Trust Quality Report 07/08/2015


3

Our ratings for The Hillingdon Hospitals NHS Foundation Trust


Overall trust Requiresimprovement


improvementRequires

improvementRequires

improvement

NotesFour individual ratings and one overall rating werereviewed as a result of this inspection. These were theratings for safe in Urgent and emergency services,Medical care, Surgery, Services for children and youngpeople and the overall rating for safe for HillingdonHospital. All other ratings are taken from our October2014 inspection findings and subsequent report.

At the time of our inspection in October 2014, we werenot confident that we were collecting su�icient evidenceto rate e�ectiveness for neither Urgent and emergencyservices / Minor injuries unit nor Outpatients anddiagnostic imaging.

Overview of ratings

8 The Hillingdon Hospitals NHS Foundation Trust Quality Report 07/08/2015


Information Governance Toolkit

The Hillingdon Hospitals NHS Foundation Trust’s Information Governance Assessment Report overall score for 2015/16 was 81%. This is termed as satisfactory (green) with all requirements level 2 or above.

Clinical coding error rate

The Hillingdon Hospitals NHS Foundation Trust was not subject to the Payment by Results Clinical Coding Audit during 2015/16 by the Audit Commission.

Action taken to improve data quality The Hillingdon Hospitals NHS Foundation Trust will be taking the following actions to improve data quality:

> Continue the comprehensive monitoring programme for data quality across the organisation through divisional based groups led by the Director of Operational Performance.

> The quality of RTT 18 week incomplete pathway data will continue to be reviewed monthly at the elective performance meetings and divisional data quality groups including diagnostic waiting lists.

> Trust Board indicators assurance - regular review and local auditing

> Expanding the Data Quality Programme to include other key datasets used at key committees.

> A focus on 18 week Referral To Treatment (RTT) training across the Trust for new and existing staff members.

Data quality

The Hillingdon Hospitals NHS Foundation Trust submitted records during April 2015 to December 2015 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data.

The percentage of records in the published data:

> which included the patient’s valid NHS number was:

– 98.6% for admitted patient care – 99.8% for out-patient care and – 96.3% for accident and

emergency care.

> which included the patient’s valid General Medical Practice Code was:

– 100% for admitted patient care; – 100% for out-patient care; and – 100% for accident and emergency

care.

The Trust’s Board and management seek to take all reasonable steps and exercise appropriate due diligence to ensure the accuracy of the data reported in relation to the quality indicators outlined in the Quality Report, but recognises that it is nonetheless subject to the inherent limitations outlined within the statement from the Chief Executive Officer earlier in this report.

The Trust has been working through a detailed improvement plan since the Care Quality Commission (CQC) published its report. This has been presented to the Trust Board and to our commissioners on a monthly basis and is available for view via the public Board papers on the Trust website.

A ‘root cause analysis’ review was undertaken to examine how the situation, which was identified by the CQC, arose. This was overseen by the Board. There has been important learning for the Trust and for the Board. As a result an accountability framework is now being developed to ensure there is clarity of responsibilities and accountabilities at every level.

The Trust’s ambition is to achieve an ‘outstanding’ (with ‘good’ as a minimum) CQC rating at a future inspection. Moving forward, the Trust has agreed a programme of mock inspections using internal peer review supported by TIAA, the Trust’s internal auditor. Several internal audits being conducted as part of the Trust’s internal audit programme examine practice and processes that support the regulations of the Health and Social Care Act (HSCA). A workshop was also held for ward sisters / charge nurses and department managers to ensure they fully understand the responsibilities of their role in achieving the fundamental standards and the requirements of the HSCA.

The Hillingdon Hospitals NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period.


3

Indicator 5: Clostridium difficile (C. diff)

The Trust has seen a reduction in the incidence of C. diff infection since 2014/15 with a total of 12 cases in 2015/16 against a trajectory of eight compared with the previous year end total of 18 cases against a trajectory of 16. A Root Cause Analysis (RCA) is undertaken for all cases of Trust attributed C.diff and the Consultant in charge of care, Consultant Microbiologist, Infection Control Nurse, Ward Sister and responsible Matron are generally part of this process.

During 2015/16 all RCA investigation reports were presented to the Clinical Commissioning Group (CCG) representative for review and scrutiny and to establish agreement regarding any lapses in care. Of the 12 cases presented to the CCG only one case was considered to be due to a lapse in care and therefore potentially avoidable as antibiotics were not prescribed in accordance with the Trust Antimicrobial Guidelines. The remaining 11 cases were predominantly elderly patients presenting as emergency admissions, acutely unwell with a history of clinically indicated antibiotic treatment in line with Trust Antimicrobial Guidelines.

Antimicrobial Stewardship is an important element in the prevention of hospital acquired C. diff and there is now a full time antimicrobial pharmacist working in the Trust

Supporting Information about the indicators required in accordance with the Quality Account regulations Update

The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: Indicator 1: SHMI

The Summary Hospital-level Mortality Indicator (SHMI) for the Trust for year 2015/16 is 0.89 (source HSCIC, benchmark period October 2014 - September 2015) and is within the ‘lower than expected’ range. The Trust intends to maintain this position and so the quality of its services by continuing to progress the implementation of the London Quality Standards, which should be reflected in a sustained SHMI performance.

Indicator 2: Palliative Care Coding

Use of the palliative care codes has stabilised over the last few years and our coding rate (for deaths specifically) is marginally higher than last year and in line with the national average. The Trust intends to improve this percentage and so the quality of its services by continuing to monitor performance via the integrated quality and performance report (reviewed monthly by the Board) and continue to ensure that reporting systems are robust and efficient through audit.

Data Inconsistencies

A number of indicators are showing changes to 2015/16 data that was published in last year’s Quality Report.There are several reasons for this as follows:

1. The statutory timescale within which the Quality Report is published is very tight. Not all of the latest data was available at the time of publication last year and so the Trust has taken the opportunity to update 2014/15 indicators with full year updates which are now available.

2. National indicators based on statistical methods by definition require re-basing (e.g. standardised readmissions, HSMR, SHMI).

3. Data quality or data completeness issues may have affected last year’s indicators. If these have been identified then they have been rectified in this year’s report.

2.3 Performance against Core Quality Indicators 2015/16

In this part of the report the Trust is required to report against a core set of national quality

indicators to provide an overview of performance in 2015/16. The following page provides

information which has been obtained from the recommended sources and is presented in line

with the detailed Monitor guidance.


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3with pre-operative questionnaires.This is the first questionnaire that is issued pre-operatively to patients in the process and is issued by the hospital.Subsequent PROMS questionnaires are issued by an external company that administers the post-operative PROMS data collection for the Trust. Our PROMS pre-operative issue rates for hip and knee replacements are higher than for groin hernia and varicose veins and this is due to the fact that questionnaires are given to patients at the pre-operative joint school.

Indicator 7: Groin hernia

There was an improvement in the hospital’s PROMS results for groin hernia between 2013/14 and 2014/15 and the Trust is performing higher than the national average. The Trust intends to improve performance on this indicator and so the quality of its services where the pre-operative nursing teams at both hospital sites will try and improve the issue rates for groin hernia and varicose veins in particular. Indicator 8: Hip replacement

There has been a slight improvement in two of the three hip replacement outcomes (EQ5D VAS and Oxford Hip Score) and the performance against the remaining outcome (EQ5D- Index) is very similar to the previous 12 months results. When benchmarked, the hospital’s results are very similar to the national average. The Trust intends to improve performance on this indicator and so the quality of its services by monitoring issue rates and improving the patient’s overall experience.

information leaflet distributed to every inpatient regarding the risk of VTE during their hospital stay and post-discharge and how to minimise that risk. The Trust has taken steps to understand the risk to patients and to share learning by RCA of all identified cases of VTE during the past year found to be Hospital Acquired Thrombosis (HAT) - defined as a VTE which occurs during admission or within 90 days of discharge from hospital. Of 33 cases of HAT identified: more than 80% had a VTE risk assessment on admission; even those without documented assessment had appropriate thromboprophylaxis (TP) – except in one case. 64% developed a VTE despite appropriate TP and a number were complex cases where re-assessment of VTE risk status and adjustment of TP might have prevented development of VTE. A few cases might have benefitted from extended TP post-surgery – although this would not have been a NICE guideline or evidence-based practice. Prescribing and documentation of TED stockings which might have reduced the risk of VTE was poor.

This information has been shared with the teams involved in order that lessons can be learned and future performance improved.

Indicator 7, 8 and 9: Patient Reported Outcome Measures (PROMS) Health Gain

For the purposes of the Annual Quality Report the PROMS data being reviewed is for the full year 2014/15.This is due to the fact that the 2015/16 data is not yet available for review due to post-operative patients still submitting post-operative information. In 2014/15 the Trust saw an increase in the number of patients being issued

helping to increase awareness and knowledge of good prescribing practice and stewardship. The infection control team is now fully established and this has strengthened surveillance opportunities and ward based teaching. The Trust intends to improve performance on this indicator and so the quality of its services by progressing a refreshed annual infection control action plan with robust oversight by the Infection Control Committee during 2016/17.

Indicator 6: Venous Thromboembolism (VTE)

The VTE risk assessment compliance for 2015/16 is 94.5% compared with 92.6% for 2014/15. After the previous year’s root cause analysis (RCA) of reasons for difficulty in delivering on the target an action plan was developed and is monitored within the Trust clinical governance system up to the Quality and Safety Committee.

The Trust has taken actions to further improve performance on this indicator and so the quality of its services which includes:

> improved staff education including junior doctors during their induction and nursing staff during education on documentation and drug administration;

> improved documentation with checklists, which include VTE assessment, in medical notes;

> involvement of ward pharmacists as part of the multidisciplinary team to draw attention to any omissions on drug charts; modification of the drug chart to aid in ease of VTE risk assessment has been approved;

> standard clinical practice that no patient is admitted to a clinical area without a VTE assessment completed.

The Trust has mitigated the risk of VTE to patients by producing an


Indicator 9: Knee replacement

The PROMs results for knee replacements have deteriorated compared with the previous 12 months and currently sit below the national average. The Trust intends to improve on this indicator and so the quality of its services; the reasons for the deterioration are being further investigated by the clinical and managerial teams and the required actions will be taken forward during 2016/17. The EQ5D outcome measures report a patient’s overall experience of surgery whereas the Oxford Knee Score (OKS) is more of an objective clinical measure.The results for the OKS are very similar to that of the national average which may indicate that there is further work to be done on improving the patient’s overall experience and managing their expectation of surgery.

Indicator 10: Friends and Family Test question 12d – Staff Survey

The narrative provided covers two quarters; due to this year’s staff survey there was no quarter three survey and quarter four data is still awaited.

For the two quarters of 2015/16, during which the Staff FFT operated, the results show an average of 77% of staff are ‘likely’ to recommend the Trust as a place in which to receive treatment whilst 72% are ‘likely’ to recommend the Trust as a place to work.

The Trust intends to take the following actions to improve staff response rates and performance and so the quality of its services:

> Increase electronic access to the questionnaire to increase participation rate

> Promote action taken as a result of feedback provided by staff through


3Indicator 13: Access to healthcare for people with a learning disability

The Trust has remained fully compliant with this key indicator as part of its quarterly and annual declaration to Monitor. The Trust intends to continue to raise awareness amongst its staff and ensure that its best practice guidance on caring for patients with a learning disability is followed so as to maintain performance on this indicator and so the quality of its services.

Definitions of the two mandated indicators for substantive sample testing by the Trust’s auditors are:

1. Referral to Treatment Time within 18 weeks for patients on incomplete pathway (18 week RTT)

2. Accident and Emergency department 4 hour target

Independent auditors are engaged by the council of governors of The Hillingdon Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of The Hillingdon Hospitals NHS Foundation Trust’s quality report for the year ended 31 March 2016 and certain performance indicators contained therein.

50% of reporters for Acute (Non-Specialist) Organisations with a rate of 36.97 (per 1000 bed days)**. This compared to a median reporting rate of 35.34 (per 1000 bed days) for the reporting period (between 1 October 2014 to 31 March 2015). Organisations that report more incidents usually have a better and more effective safety culture. It is well recognised that you can’t learn and improve if you don’t know what the problems are.

The number of patient safety incidents that resulted in severe harm or death has decreased from the previous year by 0.4%. The Trust intends to take the following actions to improve further on this key patient safety indicator and so the quality of its services:

> Continue to raise awareness of the importance of incident reporting and in particular near misses and no/low harm incidents (this will ensure learning to avoid the more harmful incidents from occurring)

> Ensure there is more robust feedback on actions taken provided to reporters to ensure staff see the value of reporting patient safety incidents

> Continue to ensure there is detailed root cause analysis investigation of all moderate/severe/death reported incidents to support learning and changes in practice.

*Excluding Pressure Ulcers Internal Transfers (PUIT) and Pressure Ulcers Admitted With (PUADM)

**Unable to compare NRLS data with previous reporting periods as indicator changed during 2015 from incidents per 100 admissions to incidents per 1,000 bed days.

the Bulletin, intranet, staff meetings and team briefings

> Continue to implement the staff engagement initiatives detailed in the strategy.

Indicator 11: Responsiveness to personal needs of our patients

This is a composite score from five questions taken from the 2015 national survey of inpatients.

> Being involved in decisions about your care and treatment

> Finding someone to talk to about worries and concerns

> Being given enough privacy when discussing your condition and treatment

> Informing patients about medication side effects to watch out for after going home

> Knowing who to contact if worried about your condition or treatment after leaving hospital

The Trust is currently awaiting the CQC survey report which is to be published in June 2016 with regard to being able to report the composite score of the above five questions. The Trust intends to critically review this data once it is received and formulate an improvement plan to improve performance on this indicator and so the quality of its services:

Indicator 12: Patient Safety Incidents

The Trust’s rate of reporting for patient safety incidents has increased from 34.86 (per 1000 bed days) in 2014/15 to 35.31* (per 1000 bed days) in 2015/16. This is a positive improvement as part of an improved patient safety culture.

Comparative data from the National Reporting and Learning Service (NRLS) shows that the Trust is in the middle


conditions such as chronic obstructive pulmonary disease (COPD). In some cases, lifestyle choices of the patient (e.g. smoking or alcohol consumption) were found to be significant contributory factors.

Where it was felt that re-admissions may, potentially, have been avoided, for example by providing new or improved services, suggestions for improvement were captured and shared with relevant stakeholders both in the Trust and in the wider health and social care environment. Themes included: improving communication between the hospital and community matrons, providing excellent end of life support for patients and their families/carers, and focusing on supporting patients and carers to develop and enhance the knowledge, skills and confidence required to manage key aspects of their own care and potentially prevent them from needing to go into hospital.

The Trust has also implemented a risk stratification tool that is being used to identify patients with the highest risks of re-admission so that they can be

and responsibilities, governance arrangements and reporting requirements of the process.

Indicator 2 – Re-admissions to hospital within 28 days

It remains a key priority for Hillingdon Hospitals to manage the risk of re-admission for our patients.

Over a period of ten months in 2015/16 (January to October) THHFT implemented an ambitious project to gather information regarding the underlying causes of re-admissions; information that would help to give both the hospital and our commissioners a more detailed understanding of the multiple factors contributing to current re-admissions rates.

More than 500 ward-based investigations were conducted, from which 75 were selected for more in-depth analysis.The majority of re-admissions were found to be unavoidable due to deterioration or exacerbation of existing long term

They represent those indicators that are of national importance that patients will want to know about and they include targets used by Monitor as part of Monitor’s Risk Assurance Framework. The indicator set includes patient experience, patient safety and clinical effectiveness indicators. The indicators covered in this year’s report are consistent with those from last year’s Quality Report. Narrative has been provided on some of these indicators to outline our performance.

Indicator 1 – Hospital Standardised Mortality Rate

The Hospital Standardised Mortality Ratio (HMSR) for the Trust for year 2015/16 is 92.1 (84.3-100.4) (source Dr Foster data, benchmark period April-Dec 2015) and is below the national benchmark of 100 but is above the London average of 84.7 (83.3-86.0). The Trust weekday and weekend HSMR have been in the ‘as expected’ range throughout the year and weekend mortality is now the same as weekday. The Trust is tracking the HSMR monthly and has a robust Mortality Review Process in place for all deaths occurring in hospital. In line with the recent NHS England Guidance: Avoidable Mortality, the Trust has formed a Mortality Surveillance Group to oversee the Mortality Review Process and draw up a policy which will clarify and document the roles

Part 3 Other key quality information and improvements we have made in 2015/16

In this part of the report we have included other key quality indicators which have been selected by the Board in consultation with stakeholders.


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3Indicator 12 – Accident and Emergency (A&E) waiting times (mandated indicator for external assurance testing)

The year-end performance against the A&E access target was 92%. Overall demand increased by 2.6%, in addition to 9% growth in emergency attendances in 2014/15.

In recognition of the challenges facing the Trust, a detailed diagnostic piece of work was jointly commissioned by Hillingdon CCG and THH to identify areas for improvement that would serve to enhance patient flow. The live action plan utilises a three pronged approach which focuses on:

> Reducing inappropriate attendances

> Achieving the four hour standard and reducing admissions

> Safely and effectively discharging patients.

Average attendances of greater than 160 patients per day presents an ongoing challenge for the clinical team working in a confined physical space. Initiatives have therefore been targeted at reducing attendances from the community, diverting patients to ambulatory care pathways and expediting discharge from the base wards to reduce the amount of time each patient spends in the Emergency Department.

Further learning is expected from The Cumberland Initiative (a movement to encourage systems thinking, simulation and modelling of healthcare scenarios to improve NHS quality of care delivery and save money) whose leads are reviewing patient discharge from hospital to home or to community / social care.

mandated by Monitor for sample testing as part of external assurance on the Quality Report.

Management have acknowledged the findings of this audit which has reported a high error rate on recording data on the RTT incomplete pathway. The audit included a limited sample of cases however a variety of issues were found.

Incomplete pathways remain under continuous scrutiny and on-going validation by Trust management. There is an on-going training programme led by the Director of Operational Performance, for all staff associated with recording and delivering the RTT pathway. The outputs of the audit will be factored in to the training programme which will be more extensive for the coming year. An on-line tool will also be made available and all new starters to the Trust will have detailed training.

Indicator 11 – Fractured neck of femur

2014/15 performance: 86%2015/16 performance: 90% There has been an improvement this year in the number of patients that have sustained a fractured neck of femur receiving surgery within 36 hours. The main reason for the delay in taking patients to theatre is patients having multiple co-morbidities which requires them to have a longer preoperative period to optimise medical fitness prior to surgery. The multi-disciplinary team continue to review each patient that has a delay to theatre so ensuring that any avoidable delays can be identified and lessons learnt. The fractured neck of femur data is also presented and reviewed in the Orthopaedic Audit morning.

given additional support to help keep them at home when they are ready to leave hospital.

Indicators 4-7 - Cancer performance

Cancer performance is being well maintained for all the national waiting times standards. The quality of services is monitored annually via the national peer review programme. Tumour specific work programmes also reflect areas for service development.

Indictors 8-10 – Referral to treatment waiting times (RTT) (mandated indicator for external assurance testing)

Simon Stevens (CEO of NHSE) informed NHS providers of changes in the RTT performance target during 2015/16. Following a review, undertaken by Sir Bruce Keogh, a decision has been made to rationalise the way RTT times are tracked and therefore the reporting against the admitted and non-admitted performance is no longer required.

The focus has been on incomplete pathway performance as it is felt that this is the measure that tracks the complete patient experience.The Trust continues to sustain excellent performance against the RTT incomplete treatment pathways standard. We plan to monitor this closely through our waiting list meetings and will continue to drive performance.

In last year’s Quality Report we included detailed information on the measurement and reporting of performance on this indicator with regard to the series of rules and guidance which is published nationally. As last year, this indicator has been reviewed by our external auditor, Deloitte, as one of the indicators


welcoming and that they communicate clinic delays to patients plus offer them beverages, which patients feel offers a personal touch. Top priority for patients is to be seen at their appointed clinic time, due to the nature and demand on some clinics this remains a challenge. The outpatient matrons are continually working with service managers to explore ways of increasing clinic capacity; which can then lead to patients being seen on time. To support this there has been an increase in the number of specialities running weekend and evening clinics. Utilisation of ad hoc clinic rooms and the provision of staff to provide additional clinic activity is also better utilised and provides additional clinic capacity to reduce over booked clinics and reduction of waiting times enabling more patients to be seen on time.

Indicator 22 – Maternity local patient experience survey

We have strengthened the Maternity Services Liaison Committee and have been able to recruit three new user representatives to work with us in ensuring the woman’s voice is heard.Significant work has been done by the team to drive up the Friends and Family responses which had dropped during SaHF transition. We continue to display “you said-we did” information learning from FFT comments and complaints as well as sharing learning with the staff. We are hoping to continue to progress our programme of liaising with hard to reach groups as this has proved a valuable exercise in understanding expectation and culture.

Indicator 23 – Independent assessment of cleanliness of hospital

Since adopting the NSC (National Specifications for Cleanliness in the NHS) and audit frequencies in February 2015, the Trust-wide score has

leaving insufficient theatre time to finish all the cases. Indicator 15 – Percentage of women who have seen a midwife or maternity healthcare professional within 12 weeks and six days of pregnancy

Although we continue to achieve a greater than 95% target to book women within the 12+6 week time frame there continues to be a challenge with regard to late bookers. The CCG and Hillingdon Public Health have committed to working with us to find a solution as the main challenges lie within the community and with public messaging regarding education and information provision. The main challenge involves the key engagement required from Public Health where there is currently some service reconfiguration. This has been raised as a significant concern with Hillingdon Clinical Commissioning Group. As a Trust we will continue to work with commissioners to enable this piece of work to commence.

Indicator 21 – Outpatient local patient experience survey

There continues to be detailed analysis of the FFT and local patient experience survey provided by patients attending outpatient departments. During April 2015 outpatient departments commenced a pilot to capture FFT feedback electronically; this has proved to be successful and it is now embedded into practice. It offers patients choice as an alternative to completing paper surveys and it has proved to be beneficial to the outpatient teams in capturing real time patient experience feedback. Current feedback is very positive regarding staff attitude and the service that they provide. There are a high number of comments received via FFT and local surveys stating staff are friendly and

The A&E four hour target quality indicator was also reviewed by our external auditor as a mandated indicator for testing as stipulated by Monitor. The findings of the audit show that there is conflicting information between supporting documentation and the Trust data; this means that there are several sources of data with regard to electronic data capture as well as times recorded on hard copy casualty cards, and some of this data was conflicting in the sample tested. This has presented issues for the review of the information available and the testing of the indicator. The A&E waiting time target is being tested nationally for the first time this year. Indicators tested for the first time typically show a high error rate, as process issues are identified.

The Trust is in the process of improving its processes and controls, including additional staff training. The Trust will be removing manual processes to ensure data is captured electronically via electronic notes and white boards.

Indicator 13 – Number of last minute elective operations cancelled for non-clinical reasons

2013/14 performance: 0.85%2014/15 performance: 0.70%2015/16 performance: 0.51% The Trust continues to improve performance with regards to reducing the number of operations /procedures cancelled on the day.This remains a priority for the Trust and each month a detailed report is provided to the Trust Board regarding the reason for each cancellation. In 2015/16 the most common reason for cancelling a patient’s operation was due to a medical complication with a previous patient which resulted in their operation taking longer than expected,


3 > Up-skilling of individual staff within the complaints team and closer working between the PALS and Complaints teams to create a flexible, multi-skilled workforce

> Activity monitoring to identify surges in activity at an early stage to ensure appropriate allocation of resources

> Divisional teams taking a proactive role in resolving concerns at an early stage, with increased personal contact with complainant

> Provision of complaints investigation training for divisional and clinical teams.

Indicator 25 – Hospital Acquired pressure Ulcers

We aimed to achieve a 15% reduction of all pressure ulcers during 2015/16. This is in line with our Sign up to Safety campaign to reduce patient harms by 50% over three years. The hospital acquired pressure ulcer rate during 2013/14 was 1.34 per 1,000 bed-days and in 2014/15 this was 1.20. For 2015/16 we narrowly missed the target with a rate of 1.1; this represents a slight reduction on the rate for 2014/15.

The reduction of hospital acquired pressure ulcers is a priority area of focus for the Sign up to Safety work and there are clear actions as part of the improvement plan. These include ward based teaching and staff attending pressure ulcer and prevention teaching sessions with Buckinghamshire New University – all sessions are fully booked for the rest of the year. There is work being taken forward on improving the availability of pressure relieving mattresses including a business case for a bed replacement programme. The Trust will also be

There were 430 complaint responses due during 2015/16, of which 70.7% (304) were completed within the timescale agreed with the complainant. This is disappointingly lower than achieved last year.Underlying reasons include increased overall volume in complaints received and also staffing challenges due to sickness absence and vacancies within the complaints management team and the operational divisions. This led to significantly low performance in June and July; this recovered in subsequent months. The monthly performance ranged from a low of 12.7% in June through to 100% in both August and December.

To ensure a similar situation does not happen in the future, and to build on the service improvement already implemented to improve the timeliness and quality of responses to complainants, the following actions are underway:

> Complaints management process being strengthened to ensure quality-focused time-driven investigatory reports

consistently met or exceeded the NSC targets for Very High Risk areas i.e. 98% achievement against a target of 98%; for High Risk areas i.e. an achievement of 96% against a target of 95%; Significant Risk areas i.e. an achievement of 90% against a target of 85%; and Low Risk areas i.e. an achievement of 85% against a target of 75%. Managerial audits undertaken by the Trust have verified the scores achieved in the regular technical cleaning audits and furthermore, two six-monthly external audits undertaken by independent assessors have also validated the Trust’s technical cleaning scores.

Indicator 24 – Percentage of complaints responded to within agreed timescales

In 2015/16 the Trust received 457 complaints, of which 89.1% were acknowledged within three working days. As the investigation period is typically 30 working days, the number of complaints on which responses were due during the financial year differs because of investigation time overlap at the beginning and end of the year.


(MRSA) positive case. The blood culture was taken within 48 hours of admission and was originally attributed to the community, however following the PIR it was agreed with the Consultant Microbiologist and Consultant Paediatrician that the positive blood culture was due to specimen contamination not a bacteraemia in the absence of clinical symptoms and a second negative culture (Table 1).

Annual compliance measured with the MRSA screening policy for elective and emergency cases was 94% and 88% respectively.

Clostridium difficile infection

The Trust has seen a reduction in the incidence of Clostridium difficile (C. diff) infection since 2014/15 with a total of 12 cases in 2015/16 against an annual trajectory of eight compared with the previous year end total of 18 cases against a trajectory of 16. A Root Cause Analysis (RCA) is undertaken for all cases of Trust attributed C. diff and the Consultant in charge of care, Consultant Microbiologist, Infection Control Nurse, Ward Sister and responsible Matron are generally part of this process (Table 2).

> Clinical processes, practices, equipment and environment are standardised and simplified

Our PSC is forging ahead and making great progress with a number of initiatives already underway. The Hillingdon Hospitals NHS Foundation Trust is involved in some of these key patient safety programmes of work and these include membership at the Foundations of Safety best practice forum, developing the role of the patient safety champion, supporting a prescribing improvement model and work to ensure effective medicines optimisation.

The PSC programme of work is aligned with and supports the national Sign up to Safety campaign which the Trust signed up to in the latter part of 2014 and is outlined earlier in this report.

Infection Control Prevention and Control

Meticillin Resistant Staphylococcus aureus

Following a Post Infection Review (PIR) undertaken by the community the Trust was attributed one Meticillin Resistant Staphylococcus aureus

ensuring that documentation of patients being transferred within the hospital is strengthened with regard to presence of pressure ulcer prior to transfer.

Improving Patient Safety

During 2015/16 the Hillingdon Hospitals NHS Foundation Trust has continued to be a member of the Imperial College Health Partners (ICHP) Patient Safety Collaborative (PSC). This is one of 15 PSCs set up to help improve the safety of patients and ensure continual learning sits at the heart of healthcare in England. As the Academic Health Science Network (AHSN) for North West London, ICHP works with its partner organisations and service users to focus on specific areas of local clinical need. Its vision is to support its partners to embed safety in every aspect of their work. This means that:

> Patient and carer views are obtained and heard at all levels as a critical indicator of safety

> There is a strong ethic of team working and shared responsibility for patient safety

> Effective safety measurement and monitoring systems are in place in all clinical settings

Table 1: Trust Attributed MRSA BSI

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2014/15 0 0 0 1 0 0 0 0 0 0 0 0

2015/16 0 0 0 0 0 0 0 0 0 1 0 0

0

1

2


acutely unwell with a history of clinically indicated antibiotic treatment in line with Trust Antimicrobial Guidelines.

Antimicrobial Stewardship is an important element in the prevention of hospital acquired C. diff and there is now a full time antimicrobial pharmacist working in the Trust helping to increase awareness and knowledge of good prescribing practice and stewardship. The infection control team is now fully established

During 2015/16 all RCA were presented to the Clinical Commissioning Group (CCG) representative for review and scrutiny and to establish agreement regarding any lapses in care. Of the 12 cases presented to the CCG one case was considered to be due to a lapse in care and therefore potentially avoidable as antibiotics were not prescribed in accordance with the Trust Antimicrobial Guidelines. The remaining 11 cases were predominantly elderly patients presenting as emergency admissions,

Table 2: Trust Attributed C. diff Infections


2014/15 0 1 1 2 0 0 1 1 4 6 1 1

2015/16 2 2 1 2 0 2 0 1 0 2 0 0

0

1

2

3

4

5

6

and this has strengthened surveillance opportunities and ward based teaching.

Meticillin Sensitive Staphylococcus aureus

In Q4 one case of Meticillin Sensitive Staphylococcus aureus (MSSA) was attributed to the Trust, taking the total reported to seven MSSA cases in 2015/16. There is no mandated threshold for MSSA.

Table 3: Trust Attributed MSSA BSI


2014/15 2 0 0 2 0 0 1 0 1 0 1 0

2015/16 1 1 0 0 0 0 1 3 0 1 0 0

0

1

2

3


This Picker survey results highlight the many positive aspects of the patient experience:

> Overall: 79% rated care 7+ out of 10

> Overall: treated with respect and dignity 76%

> Doctors: always had confidence and trust 73%

> Hospital: room or ward was very/fairly clean 95%

> Hospital: toilets and bathrooms were very/fairly clean 93%

> Care: always enough privacy when being examined or treated 87%.

There are five questions where the Trust has a score that is significantly higher than the 2014 score. These are:

> A&E Department: not given enough privacy when being examined or treated

> Hospital: room or ward not very or not at all clean

> Hospital: felt threatened by other patients or visitors

> Discharge: not told who to contact if worried

> Discharge: Staff did not discuss need for further health or social care services.

The Trust scored significantly lower than the 2014 score in 1 question:

> Surgery: results not explained in clear way.

There were two areas where the Trust scored ‘better’ than most other hospitals:

> Planned admission: not offered a choice of hospitals

> Hospital: patients using bath or shower area who shared it with opposite sex.

Based on the Picker results (agency commissioned by the Trust to undertake the survey) and in comparison with other trusts that

reviewing a complaint, an action plan is drawn up to address failings identified. Examples of specific improvement actions implemented as a result of complaints include:

Issue identifiedA patient suffered delay in receiving their follow up appointment following a urodynamic test.

What we have done about it:A formal pathway has been developed by the gynaecology service to ensure all patients receive a follow up appointment within 6 weeks of a urodynamic study.

Issue identifiedA patient did not receive adequate pain relief after an operation

What we have done about it:New pain relief administration pumps have been purchased.

Staff have received additional training on pain relief and the use of the new pumps.

National Patient Survey

A survey of inpatients is part of the annual mandatory survey programme for acute trusts; this assists organisations to find out about the experience of patients when receiving care and treatment at their hospitals. The results of the 2015 survey are based on responses from 453 patients who completed the survey, giving a response rate of 37%. The average response rate of all trusts who commissioned Picker Institute Europe to conduct their survey (over half of acute trusts use Picker) was 45%. The Trust is awaiting publication of the CQC survey report to review its position against all other acute trusts participating in the survey; this will be published in June 2016.

Patient Experience – Listening to our patients

We aim to be a listening and learning organisation, in which concerns that are raised by patients are understood, shared and responded to. Listening to feedback enables our staff to gain a real insight into the patient’s experience of care. We use a number of different approaches, all of which provide us with information about what we are doing well and where we need to improve.

> National and local surveys

> Friends and Family Test

> Compliments/complaints

> PALS concerns.

What our inpatients have told us:

92% for treating patients with dignity and respect

86% for communication, involvement and information

91% for confidence and trust in our doctors and nurses

86% for meeting physical needs

Source: 2015/16 local inpatient survey based on nine months data on responses from 1,832 inpatients

How we have responded to our patients’ feedback about their experience?

Complaints

Although often uncomfortable to hear, complaints provide us with the opportunity to learn from our patients and their families and improve the services and care we provide. When


3themes that should be our focus for improvement during 2016/17.There are a number of transformational programmes underway that have links to the areas for improvement to some of the themes set out above including Transforming Inpatient Care and workforce transformation. Improving patient experience is identified as a positive outcome from these programmes.

Improving communication with patients is embedded in priority three on this report, we will be scoping out specific initiatives and actions that will make a difference to these areas. The local survey programme will enable the Trust to monitor progress on any initiatives and report into the Trust’s Experience and Engagement forum.

use Picker for their surveying the Trust has been rated as worse in questions associated with:

> Admission

> Environment and food

> Clinical care

> Surgery

> Discharge,

The CQC adult inpatient survey provides a helpful annual check of our inpatients’ experience and enables the Trust to compare our performance with that of other trusts. Overall the 2015 survey results show that there are a number of areas where patients have reported a worse experience compared to the previous year.

The survey results have been triangulated with other sources of feedback to help identify the

Inpatient94.4%

Outpatients93.5%

Maternity95.8%

A&E93.4%

Paediatrics97.6%

Daycare98%

Minor injuries98.2%

Inpatient1.4%

Outpatients0.6%

Maternity1.4%

A&E3.0%

Paediatrics0%

Daycare0.34%

Minor injuries0.5%

Positive Responses

Negative Responses

Friends and Family Test

The Friends and Family Test (FFT) provides a simple and standardised way of collecting patient experience feedback. The FFT question asks patients to consider their recent experience in the hospital ward/department or clinic and rate how likely they would be to recommend the area to a friend or family member. Patients should be given the opportunity to complete an FFT survey. During 2015/16 over 25,000 (April 2015 to March 2016) took up this opportunity and answered the FFT question. Our results for this period are set out below:


How do our FFT results compare with others?

The graphs below show the FFT results and response rate for A&E and inpatients for 2016 (the most recently published data – February 2016).

Response rate and percentage of positive and negative results for A&E

The response rate for A&E in February is lower than the England and London rate. We do significantly better however than England and London in relation to the percentage of people who recommend the service and a positively lower percentage for those who do not recommend.

Response rate and percentage of positive and negative results for Inpatients

The percentage of people who would recommend is equal to the England and London score.We have a lower percentage of patients who would not recommend in relation to London and England. The response rate for inpatients in February was in line with the London and England rates.

We have not achieved our FFT response rate targets for 2015/16, with inpatients at 21% against a target of 30%, A&E – 9.6% and maternity – 16.4%, both against a target of 20%. The Head of Public Engagement has been working closely with divisional leads to identify how they can ensure patients are consistently given the opportunity to complete the survey. This has led to significant improvement for inpatient and maternity returns received in recent months: maternity exceeded their 20% target in February (36%) and March (32.3%); inpatient response rates have been on an upward

trend for the last three consecutive months. A&E will shortly be trialling electronic data capture as an alternative to paper-based systems.

In February we contracted a new provider for collating and analysing our FFT responses. We are confident this will improve both response rates and the quality and scope of intelligence we derive from the returns due to:

> Feedback available at departmental level, for all staff

> User-friendly system, with capability to drill-down across a range of themes, age-ranges and demographic groups

> Ability to create visually stimulating poster reports to aid patient interest and engagement

> Multiple options for obtaining responses such as texting and online systems

Friends and Family Test: A&E

Data: Feb 2016

13.3% 14.6%

7.6%

85% 84.0% 91.0%

8.0% 9.0% 4.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

England London THHFT

Response Rate Percentage Recommended

Percentage Not Recommended

Friends and Family Test: Inpatient

Data: Feb 2016

24.1% 24.7% 24.3%

95.0% 95.0% 95.0%

2.0% 2.0% 1.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

England London THHFT

Response Rate Percentage Recommended

Percentage Not Recommended


3

Accident & Emergency‘Staff were very helpful

and attentive. We were

well informed of what was

happening. We felt confident

that everything that was

needed was done’

Inpatient ward‘They made my stay an

absolute pleasure. I wish

to thank everyone for their

compassion and care’

Maternity‘Excellent care, couldn’t

fault anything. Thank you so

much, felt completely safe

and in excellent hands’

What patients have told us is good about their experience

Waiting times in Accident & Emergency

are too long

Patients feel that they are asked the same questions by different professionals

Antenatal clinic is very busy, waiting area is very small with a

lack of seating. Better system required for informing about clinic delays

What patients have told us could be improved

ActionHospital wards have become specialty based enabling doctors to undertake timely ward rounds leading to earlier discharge of patients in the day and improved patient flow from A&E.

ActionThe development of the Hillingdon Care Record which is a mobile application running on Trust iPads will enable clinical staff to view the medical history of patients reducing the need for patients to provide the same information to different professionals.

ActionA review of antenatal capacity is being undertaken to look at numbers of patients attending and appropriateness of appointments.


Staff Survey Headlines

In 2015, the Trust delivered overall an encouraging staff survey result.In terms of the standard and quality of care we provide, 65% of our staff said they ‘would recommend the Trust as a place to work’. This is 4% higher than the average for acute Trusts. There was a slight increase (66% in 2015) in the percentage of staff that would be happy with the standard of care provided by the Trust to friends or relatives. However, this was lower (4%) than the average for acute Trusts (70%). The Trust will take the following actions to maintain and further improve its performance:

> Build on work to date on developing highly effective teams to continue to improve quality of care

> Increase access to learning and development opportunities at all levels within the Trust to build clinical skill sets and improve the patient experience

> Increase opportunities for work based learning to promote learning and broaden clinical skills to elevate the standard of care

> Continue to work collaboratively with divisions to devise and implement bespoke local initiatives to drive learning, knowledge and innovation.

As requested by Monitor the following are our most recent results on key findings (KF) from the staff survey:

KF19: Organisation and management interest in and action on health/well-being: The Trust scored 3.61 on this question and our score is above (better than) average compared with other acute trusts who scored 3.57.

KF21: Percentage of staff believing the organisation provides equal opportunities for career progression/promotion: Over the last three years the number of staff responding positively to this finding has increased with 83% this year. Other acute trusts reported 87%.In terms of breakdown by ethnic categorisation, 90% of staff by White ethnic backgrounds said they believed that the organisation provided equal opportunities for career progression/promotion compared to 73% of BME (Black and minority ethnic) staff. Benchmarked against other acute Trusts, they reported 89% (White) and 75% (BME) respectively.

KF25: Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months: 31% for White staff and 25% for BME staff. This is a 4% increase for both groups over the previous year.

KF26: Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months: 23% of staff who answered this question in the survey said they had experienced this in the last 12 months. This is below (better) than average compared to other similarly sized trusts that reported 26%. This was a slight increase on our performance in 2014 (22%). In terms of breakdown by ethnic categorisation, 24% of staff by White ethnic backgrounds said they had experienced harassment compared to 22% of BME staff. Benchmarked against other acute Trusts, they reported 25% (White) and 28% (BME) respectively.

KF27: Percentage of staff reporting most recent experience of bullying, harassment or abuse: 43% of staff who answered this question in the survey said they had reported bullying, harassment or abuse in the last 12 months. The Trust was in the highest

(best) 20% of Trusts. Other acute Trusts reported 37% of staff reporting on this.

Equality and Diversity

Our Staff

More than 92% of staff completed their core equality and diversity training and remain compliant with refresher training. Over the last year the Trust has invested in a range of interventions to address feedback from the 2014 staff survey response. This has included:

> Promoted the “Ready Now” NHS Leadership Academy programme for black and minority ethnic communities (BME) staff

> Rolled out our popular Customer Care programme

> Included employee relations cases in Board level KPIs

> Work with external consultants to scrutinise Trust systems and process against the nine protected characteristics. This emanated in focus groups which have provided rich data that will formulate an action plan in 2016

> Implemented new development programmes for Agenda for Change Bands 3-5 and 6-7, previously not included in internal Leadership Programme, and rolled out the Leadership 100 programme to additional cohorts at Bands 8 and above.

In response to experiences of discrimination, the Trust is embarking on a variety of projects including –

> Establish Equality, Diversity and Inclusion (EDI) Steering Group with Board level leadership to drive Trust EDI priorities

> Rollout of ‘Speak In Confidence’ anonymous dialogue system which enables staff to raise concerns they may have and to escalate anonymously.


3Patients

The Trust is committed to equality, diversity and human rights. This means we work to make sure our staff and patients and communities are treated fairly and with respect. We aim to develop an inclusive culture where diversity is fully embedded into business practice. We also aim to influence change around reducing health inequalities and improving the patient experience whilst promoting a culture that embraces diversity and delivers measurable benefits.

The Trust has a growing BME workforce broadening the talent and diversity of our workforce. The Trust is committed to creating a working environment in which its employees are treated fairly, feel valued and are engaged. It is working hard to promote equality in everything it does by embedding its CARES values of which ‘equity’ is one.

The Staff Survey results enable us to compare metrics for the responses from White and BME staff and the new Workforce Race Equality Standard (WRES) provides a measure of the experiences of our White and BME workforce in accessing learning and development and career opportunities.

Action on staff survey results and equality and diversity issues for the workforce

Data: There is ongoing work to improve our data collection and reporting and recent work with external consultants to review our procedures and processes along the nine protected characteristics. Findings will be implemented.

> Bullying and Harassment: Build on the work with ‘Speak In Confidence’ which has prioritised the issue of bullying and harassment. At a local level broaden the capacity and capability of our CARES Ambassadors in providing individual and local support to victims of bullying and harassment

> Review our zero tolerance campaign around the issue

> Increase range of learning and development opportunities offered to staff particularly those at bands 1-4

> Improve education and training governance including the improving of access to learning opportunities along the nine protected characteristics.

> Broaden our range of cultural awareness and Equality and Diversity training to support recruitment and selection and key decision points.

The Trust prides itself on the fact that it does engage and will continue to engage the service users and staff to deepen its understanding of the equality themes. Engaging with our local communities that we serve and providing opportunities for service users to feed back on their experience is an important feature of our work.


experience through completing an easy-read survey.

3. Improving services for people with a sensory disabilityThe Trust has engaged with service users with a sensory disability to capture their feedback on their experiences of accessing our services and receiving care. These included both positive and negative viewpoints. This has been invaluable in terms of ensuring our services are responsive to the needs of this group of service users. Some of these service users have expressed an interest to be involved in the design of new services. This will be taken forward by a task and finish group in 2016/17.

In 2015/16 the Trust installed additional hearing induction loops based on feedback from patients. The introduction of the hearing loop system not only improves communication for these patients but also ensures their privacy, dignity and well-being.

Signage has been improved across both sites to ensure easier way-finding for patients and visitors. In addition the Trust has a contract with One Stop Language Services for the provision of BSL for patients using our services.

of which will provide more guidance about which service developments we should prioritise.

2. Caring for people with a learning disabilityIn order to provide assurance that the Trust is listening and responding to the needs of patients with a Learning Disability, the Head of Safeguarding has attended a variety of forums where there are carers and service users. This is an excellent opportunity to hear the views of people to respond to their questions, and improve outcomes.The Trust ensures staff awareness with regard to the need to listen and make reasonable adjustments for those with a learning disability. Clinical and non-clinical staff receive awareness training as part of their mandatory safeguarding training making them more aware of the needs of learning disability patients and their carers.

The Good Practice Guidelines for staff working with people with learning disabilities remain in place. There are also care pathways for patients with learning disabilities in A&E, outpatients and the radiology department which continue to be used for patients with learning disabilities.

Patients with a learning disability can provide feedback to the Trust on their

Our equality objectives for 2015/16 were:

1. Caring for patients with dementiaImprovements in dementia care have continued throughout the year. Ensuring all relevant patients are screened for potential signs of dementia, and referred for follow up as indicated, has remained a priority, with over 1,950 patients over 75 years admitted as an emergency having been assessed within 72 hours of admission.

Staff education has similarly remained a priority, with all staff receiving dementia awareness training on joining the Trust. This is delivered by the Dementia Clinical Nurse Specialist and is presented from the eyes of a patient, using the critically acclaimed “Barbara’s Story” DVD; this has now been seen by 3,569 staff. Doctors, nurses and therapists receive more detailed bespoke clinical training and several go on to undertake the Alzheimers’ certificate or, for specific staff, a specialist module at university.

As well as welcoming carers to support their loved ones outside of visiting hours, experience for inpatients with dementia has been improved by the provision of more activities such as reminiscence rummage boxes, “fidget blankets”, singing and music sessions and provision of books, puzzles and board games. We continue to advocate an inclusive approach for patients with dementia, and aim to incorporate dementia-friendly design and facilities across the whole Trust.

Future work is being driven by patient and carer feedback. All carers are offered the opportunity to complete a short survey about their experience while at the Trust. We will be participating in the National Dementia Audit early in 2016/17, the results

The Good Practice Guidelines for staff working with people with learning disabilities remain in place


3Annex 1 Statements from our stakeholders Statement from Hillingdon Clinical Commissioning Group (CCG)


3


Statement from our local Healthwatch


3


3(although the cause is unclear). The Committee is aware that an audit of the patient pathway will be undertaken in the next few months, from blue light arrival through to discharge. It is hoped that this audit will also consider what has had happened to each patient prior to being transported under blue lights, to ensure that a fuller picture can be gleaned and analysed. The Committee looks forward to receiving an update on any action that is taken as a result of this audit to reduce activity.

It is noted that the Trust has developed four key areas for improvement in 2016/2017 on which the following draft Quality Priorities for the forthcoming year have been based:

1. Achieving NEWS compliant to support early escalation of the deteriorating patient

2. Achieving improvement in relation to seven day working priorities

3. Delivering compassionate care and improving communication

4. Safer staffing – improved recruitment and retention to ensure delivery of safe care.

Looking forward, there are areas where the Trust continues to demonstrate that progress and improvements have been made but the Committee notes that there are a number of areas where further improvements are still required.We look forward to being updated on the progress of the implementation of priorities outlined in the Quality Report over the course of 2015/16.

the issues raised by the CQC during its inspections and that the resultant improvement plan is regularly audited and monitored.

Members are encouraged to see that the Trust has made progress in relation to increasing the number of patients receiving enhanced MCA/DoLS training as well as establishing an Equality and Diversity group and attending local disability groups. In addition, the Trust has achieved 85% satisfaction with pharmacy services (against a target of 75%) and 97% satisfaction in relation to women experiencing a positive experience in the new birth centre (against a target of >88%).

Although there has been an improvement in relation to an increase in reporting of medicine errors from 7.8% to 9%, the Trust has not met its >11% target this year. Furthermore, 63.3% of FFT respondents advised that they had been informed and updated of waiting times, if they had been waiting for more than 20 minutes, against a target of 80%. Members are also aware that consideration has been given to communication with patients and staff, particularly with regard to delays and 7 day working. The Committee looks forward to receiving updates on the effectiveness of measures put in place to address these issues.

The Committee is aware that there has been a significant increase in activity at the Trust in the last two years and that it has one of the smallest A&E departments in London. As Hillingdon Hospital’s A&E department is working at capacity, the Trust is having to work more smartly whilst also being conscious of keeping momentum going in relation to the drive for quality and delivering against financial targets.In addition, the Urgent Care Centre regularly becomes very busy, which has a knock on effect on A&E, and the number of patients arriving by ambulance is increasing across London

Consultation on the Trust’s Quality Report – 2015/2016

Response on behalf of the External Services Scrutiny Committee at the London Borough of Hillingdon

The External Services Scrutiny Committee welcomes the opportunity to comment on the Trust’s 2015/2016 Quality Report and acknowledges the Trust’s commitment to attend its meetings when requested. The Committee is delighted that the Trust has received national recognition for outstanding core skills compliance by the London Streamlining Programme, which recognises that the Trust has raised its mandatory training compliance levels to over 90% and maintained this over the year.

The Trust’s four Quality Priorities during 2015/2016 were:

1. Ensuring the safety of vulnerable and older people

2. Improving the safety of medicines management

3. Improving maternity services4. Improving communication with

our patients

Following the October 2014 inspection, the CQC undertook its re-inspection of the Trust in May 2015.As a robust improvement plan had been put in place, this visit resulted in a de-escalation of warning notices in relation to regulations 10 and 12. Although there had been significant improvements with regard to Safe Care and Treatment for Cleanliness and Infection Control in relation to bare below the elbows and hand hygiene since the last CQC visit, the Trust has received a requirement notice against regulation 12.The Committee appreciates that the Trust has put a lot of time and resources into addressing


have not been met with regard to the quality priorities set for 2015/16. It has also been recognised that the Trust has been committed to continuing to improve the quality of its services and impact positively on the patients’ experience of care despite the unprecedented activity that the Trust has seen in the last year. Improving communication with our patients will continue to be a key priority in 2016/17. We recognise the concern raised by our stakeholders on the progress of improvement in this area during 2015/16. We acknowledge, as outlined by Healthwatch Hillingdon, that our patients report that the care they receive and the compassion shown by our staff is excellent but that communication issues can be an area of frustration and angst.

We look forward to continuing our very positive working relationships with our key stakeholders to support the delivery of improved quality of care and patient experience.

acknowledged that the Trust has progressed extensive work following the Care Quality Commission inspection to further improve the quality of its services.

Areas of underperformance have been acknowledged and the Trust would like to reassure its stakeholders that these areas will continue to be a key priority for the Trust and a focus in the forthcoming year. This includes A&E performance against the 4-hour target, response rates for FFT and complaints response rates.

The Trust is pleased that the ESSC recognises the amount of work that has been undertaken by the Trust over the last year with regard to achieving its quality priority targets. The Trust also welcomes the acknowledgement by the ESSC of the activity that we have seen through our A&E department and the work that is being taken forward to understand the reasons for the increase and how this is going to be managed.

The Trust acknowledges and welcomes the recommendations put forward by Healthwatch Hillingdon and our local commissioners with regard to strengthening its quality priorities. The Trust has reviewed the targets outlined and provided timelines for achievement. The Trust has also included the Accessible Information Standard under Priority 3 (Improving Communication) as a key target to achieve. This will ensure that that people who have a disability, impairment or sensory loss get information that they can access and understand and any communication support that they need.

Our stakeholders have recognised that we have presented an honest and robust summary of the overview of quality of care at the Trust, acknowledging, alongside our achievements, that some targets

The Hillingdon Hospitals NHS Foundation Trust response to the consultation

The Hillingdon Hospitals NHS Foundation Trust thanks all its stakeholders for their comments about the 2015/16 Quality Report.

The Trust is pleased that our key stakeholders recognise the Trust’s commitment to improve the quality of the care and services that we provide and to work closely with them in achieving further improvement. The Trust enjoys a good working relationship with both Healthwatch Hillingdon and with the Hillingdon Clinical Commissioning Group and it looks forward to further collaborative working to help shape the quality agenda and the delivery of safe, high quality care.

The Trust is also pleased that its key stakeholders are in agreement with its quality priorities for 2016/17, recognising where we have made good progress in quality improvement across a range of quality indicators and also where further work needs to be driven forward to realise the expected outcomes that we wish to achieve.

The Trust has taken comments on board as part of the consultation for the Quality Report and as such these are aligned with our partners’ views on where we need to focus our efforts. These are recognised by our key stakeholders and it is very positive that both Healthwatch Hillingdon and our local commissioners wish to continue to work closely with us.

Our stakeholders have recognised and commended our excellent scores on the FFT, our improved mortality rates, our cancer performance and the reduction in Clostridium difficile infections. It has also been


3annual reporting manual’ and the six dimensions of data quality set out in the ‘Detailed guidance for external assurance on quality reports’.

We read the quality report and consider whether it addresses the content requirements of the NHS foundation trust annual reporting manual, and consider the implications for our report if we become aware of any material omissions.

We read the other information contained in the quality report and consider whether it is materially inconsistent with:

> Board minutes for the period 6 April 2015 to 23 May 2016;

> Papers relating to quality reported to the Board over the period 1 April 2015 to 27 May 2016;

> Feedback from Commissioners, dated 12 May 2016;

> Feedback from governors, dated 10 May 2016;

> Feedback from local Healthwatch organisations;

> The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009;

> The latest national patient survey;

> The latest national staff survey;

> Care Quality Commission Quality Report dated 7 August 2015;

> The Head of Internal Audit’s annual opinion over the Trust’s control environment dated 19 April 2016.

We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively the ‘documents’). Our responsibilities do not extend to any other information.

Scope and subject matter

The indicators for the year ended 31 March 2016 subject to limited assurance consist of the national priority indicators as mandated by Monitor:

> Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways; and

> Percentage of patients with a total time in Accident and Emergency (“A&E”) of four hours or less from arrival to admission, transfer or discharge

We refer to these national priority indicators collectively as the ‘indicators’.

Respective responsibilities of the directors and auditors

The directors are responsible for the content and the preparation of the quality report in accordance with the criteria set out in the ‘NHS foundation trust annual reporting manual’ issued by Monitor.

Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that:

> The quality report is not prepared in all material respects in line with the criteria set out in the ‘NHS foundation trust annual reporting manual’;

> The quality report is not consistent in all material respects with the sources specified in section 2.1 of the Monitor 2015/16 ‘Detailed guidance for external assurance on quality reports’; and

> The indicators in the quality report identified as having been the subject of limited assurance in the quality report are not reasonably stated in all material respects in accordance with the ‘NHS foundation trust

Independent auditor’s report to the council of governors of The Hillingdon Hospitals NHS Foundation Trust on the quality report

We have been engaged by the council of governors of The Hillingdon Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of The Hillingdon Hospitals NHS Foundation Trust’s quality report for the year ended 31 March 2016 (the ‘Quality Report’) and certain performance indicators contained therein.

This report, including the conclusion, has been prepared solely for the council of governors of The Hillingdon Hospitals NHS Foundation Trust as a body, to assist the council of governors in reporting The Hillingdon Hospitals NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2016, to enable the council of governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and The Hillingdon Hospitals NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing.


Issues identified for 18 week referral to treatment included:

> The published indicator incorrectly includes records which should be excluded from the calculation; and

> The published indicator include cases where incorrect pathway start dates or stop dates are being applied for which corrective action has been taken on a number of cases through the Trust’s internal validation processes.

As a result of the issues identified, we have concluded that there are errors in the calculation of the 18 week Referral-to-Treatment incomplete pathway indicator. We are unable to quantify the effect of these errors on the reported indicator for the year ended 31 March 2016.

Issues identified for A&E 4 hour wait included:

> Our testing identified that the Trust does not retain an audit trail for adjustments made to the underlying data as part of the validation process. Documentation is not always available to evidence the rationale for amending individual A&E attendance durations.

> Conflicting information between supporting documentation and Trust data; and

> The NHS England guidance for recording clock starts related to ambulance handovers is incorrectly applied.

As a result there is a limitation upon the scope of our procedures which means we are unable to complete our testing and are unable to determine whether the indicator has been prepared in accordance with the criteria for reporting A&E 4 hour waiting times. In addition, we are unable to quantify the effect of the errors identified on the reported indicator for the year ended 31 March 2016.

Limitations

Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information.

The absence of a significant body of established practice on which to draw allows for the selection of different, but acceptable measurement techniques which can result in materially different measurements and can affect comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision of these criteria, may change over time. It is important to read the quality report in the context of the criteria set out in the ‘NHS foundation trust annual reporting manual’ and the explanation of the basis of preparation of the 18 week Referral-to-Treatment incomplete pathway indicator set out on page 141 which sets out the approach the Trust has taken to patients with “unknown” clock start dates.

The scope of our assurance work has not included testing of indicators other than the two selected mandated indicators, or consideration of quality governance.

As set out in the Trust’s Quality Report, the Trust identified a number of issues in respect of data quality in the referral to treatment within 18 weeks for patients on incomplete pathways indicator and percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge indicator reporting during the year that was supported by our testing.

We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts.

Assurance work performed

We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included:

> evaluating the design and implementation of the key processes and controls for managing and reporting the indicators;

> making enquiries of management;

> testing key management controls;

> limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation;

> comparing the content requirements of the ‘NHS foundation trust annual reporting manual’ to the categories reported in the quality report; and

> reading the documents.

A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.


3The Trust’s Quality Report summarises the actions the Trust is taking post year end to address the issues identified in relation to the documentation of its validation processes.

Qualified conclusion

Based on the results of our procedures, except for the matters set out in the basis for qualified conclusion paragraph above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016:

> the quality report is not prepared in all material respects in line with the criteria set out in the ‘NHS foundation trust annual reporting manual’;

> the quality report is not consistent in all material respects with the sources specified in ‘Detailed guidance for external assurance on quality reports 2015/16’; and

> the indicators in the quality report subject to limited assurance have not been reasonably stated in all material respects in accordance with the ‘NHS foundation trust annual reporting manual’.

Deloitte LLPChartered AccountantsSt Albans 26th May 2016


effectively in practice

> the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and

> the Quality Report has been prepared in accordance with Monitor’s annual reporting manual and supporting guidance (which incorporates the Quality Accounts Regulations) as well as the standards to support data quality for the preparation of the Quality Report.

The directors confirm to the best of their knowledge and belief they have complied with the above requirement in preparing the Quality Report.

By order of the board

– papers relating to quality reported to the Board over the period April 2015 to 27th May 2016 (date of statement)

– feedback from commissioners dated 12th May 2016

– feedback from governors dated 10th May 2016

– feedback from local Healthwatch organisations dated 6th May 2016

– feedback from the External Services Scrutiny Committee dated 15th May 2016

– the Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 25th May 2016

– the latest national patient survey published - June 2016 (this is awaited)

– the latest national staff survey dated 23rd February 2016

– the Head of Internal Audit’s annual opinion over the Trust’s control environment dated19th April 2016

– CQC Report dated (May 2015 re-inspection) 7th August 2015.

> The Quality Report presents a balanced picture of the NHS foundation Trust’s performance over the period covered

> The performance information reported in the Quality Report is reliable and accurate

> There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working

The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year.

Monitor has issued guidance to NHS foundation Trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation Trust boards should put in place to support the data quality for the preparation of the Quality Report. In preparing the Quality Report, Directors are required to take steps to satisfy themselves that:

> The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2015/16 and supporting guidance

> The content of the Quality Report is not inconsistent with internal and external sources of information including:

– board minutes and papers for the period April 2015 to 27th May 2016 (date of statement)

Annex 2 – Statement of Directors’ responsibilities in respect of the Quality Report

By order of the board

Shane DeGarisChief ExecutiveThe Hillingdon Hospitals NHS Foundation Trust26th May 2016

Richard Sumray ChairThe Hillingdon Hospitals NHS Foundation Trust26th May 2016


3GlossaryA

Accountable Care Partnership (ACP)

The ACP is a new organisational form which integrates care around patients. It is a partnership between primary, acute, community, social care and third sector providers who have agreed to take responsibility for providing all care for a given population for a defined (and long) period of time. Most importantly, the partnership is held to account for achieving a set of pre-agreed quality outcomes within a given budget.

Acute Myocardial Infarction

Acute myocardial infarction is the medical name for a heart attack. Heart attacks occur when the flow of blood to the heart becomes blocked. They can cause tissue damage and can even be life-threatening.

Allied Health Professionals(AHPs)

These are health care professions distinct from nursing, medicine, and pharmacy. AHPs include everything from podiatrist, dietitian, and physiotherapist, diagnostic radiographer to Occupational Therapist, Orthoptist and Speech and Language Therapist.

Ambulatory Care Pathway

Allows patients who are safe to go home to be managed promptly as outpatients, without the need for admission to hospital, following an agreed plan of care for certain conditions.

Analgaesia Medication that acts to relieve pain.

B

Berwick Review Commissioned following the Mid Staffordshire Hospitals enquiry and publication of the Francis Report. The review includes recommendations to ensure a robust nationwide system for patient safety.

Better Care Fund (BCF) This is a programme spanning both the NHS and local government. It has been created to improve the lives of some of the most vulnerable people in our society, placing them at the centre of their care and support, and providing them with ‘wraparound’ fully integrated health and social care, resulting in an improved experience and better quality of life.

British Sign Language (BSL)

BSL is the sign language used in the United Kingdom (UK), and is the first or preferred language of some deaf people in the UK.

British Thoracic Society (BTS)w

The British Thoracic Society exists to improve standards of care for people who have respiratory diseases and to support and develop those who provide that care.

C

Care Pathway Anticipated care placed in an appropriate time frame which is written and agreed by a multidisciplinary team.

Care Quality Commission (CQC)

The independent regulator of health and social care in England.www.cqc.org.uk

Care Quality Commission (CQC) Intelligent Monitoring System

A form of monitoring to give CQC inspectors a clear picture of the areas of care that need to be followed up within an NHS acute Trust. Together with local information from partners and the public, this monitoring helps the CQC to decide when, where and what to inspect. 160 acute NHS Trusts are grouped into six priority bands for inspection based on the likelihood that people may not be receiving safe, effective, high quality care. Band 1 is the highest priority Trusts and band 6 the lowest.

CAS card Casualty Card – patient record that is completed within the Accident and Emergency department

Category 1 (blue-light) ambulances

Ambulance response category for presenting conditions, which may be immediately life threatening and should receive an emergency response.


Cheshire West judgement

This judgment clarified the test and definition for Deprivation of Liberty for adults who lack capacity to make decisions about whether to be accommodated in care. This means that a much greater number of service users and patients will now be subject to a deprivation of liberty and will come under the protection of the DOLS procedure.

Chronic Obstructive Pulmonary Disease (COPD)

COPD is a group of progressive lung diseases (more commonly chronic bronchitis and emphysema) that obstruct airflow. Symptoms develop slowly and over time, COPD can make it hard to perform routine tasks. The most common cause of COPD is smoking.

Clinical audit A quality improvement process that seeks to improve patient care and outcomes by measuring the quality of care and services against agreed standards and making improvements where necessary.

Clinical Negligence Scheme for Trusts (CNST) – Maternity

Administered by the NHS Litigation Authority (NHSLA), provides an indemnity to members / their employees in respect of clinical negligence claims. Trusts are assessed on their level of risk management against detailed standards.

Clostridium Difficile infection (C-Diff)

A type of infection that occurs in the bowel that can be fatal. There is a national indicator to measure the number of C. Difficile infections that occur in hospital.

Commissioning for Quality and Innovation (CQUIN)

A payment framework enabling commissioners to reward quality by linking a proportion of the Trust’s income to the achievement of local quality improvement goals.

Community Acquired Pneumonia

Inflammatory condition of the lung usually caused by infection and acquired from normal social contact (that is, in the community) as opposed to being acquired during hospitalisation.

Complicated Diverticulitis

Complicated diverticulitis refers to the clinical presentation of acute diverticulitis with inflammatory manifestations and complications, such as perforation or obstruction.

Computerised Tomography (CT)

This is an X-ray procedure that combines many X-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body

D

Delirium Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of your environment. The start of delirium is usually rapid — within hours or a few days.

Department of Health (DH)

The government department that provides strategic leadership to the NHS and social care organisations in England. www.dh.gov.uk

Deprivation of Liberty Safeguards (DoLS)

The Deprivation of Liberty Safeguards are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom.

Diabetic Ketoacidosis (DKA)

Consistently high blood glucose levels can lead to a condition called diabetic ketoacidosis (DKA). This happens when a severe lack of insulin means the body cannot use glucose for energy, and the body starts to break down other body tissue as an alternative energy source. Ketones are the by-product of this process. Ketones are poisonous chemicals which build up and, if left unchecked, and will cause the body to become acidic – hence the name ‘acidosis’

Dr Foster An organisation that provides healthcare information enabling healthcare organisations to benchmark and monitor performance against key indicators of quality and efficiency.

E

Eighteen (18) week wait A national target to ensure that no patient waits more than 18 weeks from GP referral to treatment. It is designed to improve patients’ experience of the NHS, delivering quality care without unnecessary delays.

Electronic Document Records System

This helps the Trust to manage clinical records in electronic format making records management more efficient and ensuring patient records are more accessible to clinicians.


3Epidural Catheter An epidural catheter is a very thin, flexible tube that is inserted into the spine (specifically, the

epidural space). Through it, the patient can receive doses of medication that stops nerves in the spinal cord from sensing pain.

Equality Act (2010) The Equality Act became law in October, 2010. It replaced previous legislation (such as the Race Relations Act 1976 and the Disability Discrimination Act 1995) and ensures consistency in what employers and employees need to do to make their workplaces a fair environment and comply with the law.

F

FAIR assessment for dementia

Find, Assess, Investigate and Refer (FAIR) - The identification of patients with dementia and other causes of cognitive impairment that prompts appropriate referral and follow up after they leave hospital and ensures that hospitals deliver high quality care to people with dementia and support their carers.

Foundation Trust (FT) NHS foundation Trusts were created to devolve decision making from central government to local organisations and communities. They still provide and develop health care according to core NHS principles - free care, based on need and not ability to pay.

Fragility Fracture Healthy bones should be able to withstand a fall from standing height; a bone that breaks in these circumstances is known as a fragility fracture.

Freedom to Speak The Freedom to Speak Up Review was a review into whistleblowing in the NHS in England and it was chaired by Sir Robert Francis.

Friends and Family Test (FFT)

An opportunity for patients to provide feedback on the care and treatment they receive. Introduced in 2013 the survey asks patients whether they would recommend hospital wards, A&E departments and maternity services to their friends and family if they needed similar care or treatment.

G

Gastro-intestinal (GI) The GI tract is a long hollow tube that extends from your oral cavity where food enters your body, via the oesophagus, stomach, small intestine, large intestine, rectum, and finally to the anus where undigested food is expelled.

‘Getting it right first time’ (GIRFT)

The ‘Getting it right first time’ (GIRFT) report published by Professor Briggs in late 2012, considered the current state of England’s orthopaedic surgery provision and suggested that changes can be made to improve pathways of care, patient experience, and outcomes with significant cost savings.

Governors The Hillingdon Hospitals NHS Foundation Trust has a Council of Governors. Governors are central to the local accountability of our foundation Trust and helps ensure the Trust board takes account of members and stakeholders views when making important decisions.

GP Commissioners GP Commissioners are responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services.

H

Health and Social Care Information centre (HSCIC)

The HSCIC is an Executive Non Departmental Public Body (ENDPB) set up in April 2013. It collects, analyses and presents national health and social care data helping health and care organisations to assess their performance compared to other organisations.

Healthwatch (formerly LINk)

Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. http://www.healthwatch.co.uk

Hospital Episode Statistics (HES)

The national statistical data warehouse for the NHS in England. ‘HES’ is the data source for a wide range of healthcare analysis for the NHS, government and many other organisations.


Hospital Standardised Mortality Ratio (HSMR)

A national indicator that compares the actual number of deaths against the expected number of deaths in each hospital and then compares trusts against a national average.

I

Independent Mental Capacity Advocate (IMCA)

IMCAs are a legal safeguard for people who lack the capacity to make specific important decisions: including making decisions about where they live and about serious medical treatment options. IMCAs are mainly instructed to represent people where there is no one independent of services, such as a family member or friend, who is able to represent the person.

Indicator A measure that determines whether the goal or an element of the goal has been achieved.

Inpatient A patient who is admitted to a ward and staying in the hospital.

Inpatient Survey An annual, national survey of the experiences of patients who have stayed in hospital. All NHS Trusts are required to participate.

K

Keogh Review A review of the quality of care and treatment provided by those NHS Trusts and NHS foundation trusts that were persistent outliers on mortality indicators. A total of 14 hospital trusts were investigated as part of this review.

L

Laparotomy (Emergency)

An emergency laparotomy is a surgical operation that is used for people with severe abdominal pain to find the cause of the problem and in many cases to treat it. A general anaesthetic is given and the surgeon makes an incision (cut) to open the abdomen (stomach area). Often the damaged part of an organ is removed and the abdomen washed out to limit any infection.

Learning from Mistakes League

A league table identifying levels of openness and transparency within NHS Trusts and Foundation Trusts.

Local Clinical Audit A type of quality improvement project involving individual healthcare professionals evaluating aspects of care that they themselves have selected as being important to them and/or their team.

London Health Programme Standards

Programme to improve the quality and safety of acute emergency and maternity services based on achieving key standards of practice.

M

Major Trauma Major trauma is any injury that has the potential to cause prolonged disability or death; this includes head injuries, life-threatening wounds and multiple fractures.

Mandatory Mandatory means ‘must’ as outlined by an organisation for the role of the staff member.

Mental Capacity Act (MCA)

The Mental Capacity Act (MCA) is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 and over. Examples of people who may lack capacity include those with: dementia, severe learning disability, brain injury, a mental health condition, a stroke or may experience unconsciousness caused by an anaesthetic or sudden accident

Meticillin-resistant staphylococcus aureus (MRSA)

A type of infection that can be fatal. There is a national indicator to measure the number of MRSA infections that occur in hospitals.

Meticillin-sensitive Staphylococcus aureus (MSSA)

MSSA can cause serious infections, however unlike MRSA MSSA is more sensitive to antibiotics.

Monitor The independent regulator of NHS foundation Trusts. http://www.monitor.gov.uk


3Morbidity Term used to describe how often a disease occurs in a specific area or is a term used to

describe a focus on death. An example of morbidity is the number of people who have cancer.

Mortality rate The number of deaths in a given area or period, or from a particular cause.

Multidisciplinary team meeting (MDT)

A meeting involving healthcare professionals with different areas of expertise to discuss and plan the care and treatment of specific patients.

N

National Clinical Audit A clinical audit that engages healthcare professionals across England and Wales in the systematic evaluation of their clinical practice against standards and to support and encourage improvement and deliver better outcomes in the quality of treatment and care.

The priorities for national audits are set centrally by the Department of Health and all NHS Trusts are expected to participate in the national audit programme.

National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

NCEPOD’s purpose is to assist in maintaining and improving standards of care for adults and children for the benefit of the public by reviewing the management of patients, by undertaking confidential surveys and research, by maintaining and improving the quality of patient care and by publishing and generally making available the results of such activities.

National Early Warning Scoring system

An early warning scoring system used to track patient deterioration and to trigger escalations in clinical monitoring and rapid response by the critical care outreach team. The scoring system used to trigger escalation is based on routine observations of respiratory rate, oxygen saturation levels, blood pressure, temperature, pulse rate and level of consciousness combined to give weighted scores that in turn trigger graded clinical responses.

National Joint Registry (NJR)

The NJR collects information on all hip, knee, ankle, elbow and shoulder replacement operations, to monitor the performance of joint replacement implants and the effectiveness of different types of surgery, improving clinical standards and benefiting patients, clinicians and the orthopaedic sector as a whole.

National Reporting and Learning System (NRLS)

The National Reporting and Learning System (NRLS) is a central database of patient safety incident reports submitted from health care organisations. Since the NRLS was set up in 2003, over four million incident reports have been submitted. All information submitted is analysed to identify hazards, risks and opportunities to continuously improve the safety of patient care.

Neonatal transitional care model

The neonatal unit provides expert, round-the-clock care for new-born babies who are ill or born prematurely. The transitional care model supports preparation for babies’ discharge home. Transitional care gives the parent a chance to take care of the baby, but with nurses nearby. This sometimes means staying on the neonatal ward with the baby for a while.

Never events Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Trusts are required to report nationally if a never event occurs.

NHS Litigation Authority(NHSLA)

Established to indemnify NHS trusts in respect of both clinical negligence and non-clinical risks. It manages both claims and litigation and has established risk management programmes against which NHS Trusts are assessed.

NHS number A 12 digit number that is unique to an individual, and can be used to track NHS patients between organisations and different areas of the country. Use of the NHS number should ensure continuity of care.

O

Oesophago-gastric Refers to the oesophagus (tube that food passes through when we swallow) and to the stomach.


Operating Framework An NHS- wide document outlining the business and planning arrangements for the NHS. It describes the national priorities, system levers and enablers needed to build strong foundations whilst keeping tight financial control.

Ophthalmology The branch of medicine that deals with the anatomy, physiology and diseases of the eye.

Outpatient A patient who goes to a hospital and is seen by a doctor or nurse in a clinic, but is not admitted to a ward and is not staying in this hospital.

Overview and Scrutiny Committee (OSC)

OSC looks at the work of NHS Trusts and acts as a ‘critical friend’ by suggesting ways that health-related services might be improved. It also looks at the way the health service interacts with social care services, the voluntary sector, independent providers and other Council services to jointly provide better health services to meet the diverse needs of the area.

P

Pancreatitis This is a disease in which the pancreas becomes inflamed. Pancreatic damage happens when the digestive enzymes are activated before they are released into the small intestine and begin attacking the pancreas.

PAS- Patient Administration System

The system used across the Trust to electronically record patient information e.g. contact details, appointment, admissions.

Patient-Led Assessment if the Care Environment (PLACE)

A system for assessing the quality of the patient environment, replacing the old Patient Environment Action Team (PEAT) inspections. The assessments apply to hospitals, hospices and day treatment centres providing NHS funded care. The assessment includes local people as part of teams to assess how the environment supports patient’s privacy and dignity, food, cleanliness and general building maintenance. It focuses entirely on the care environment and does not cover clinical care provision or how well staff do their job. The assessments take place every year, and results are reported publicly to help drive improvements in the care environment.

Patient Safety Incident A patient safety incident is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care.

Picker patient experience survey

Picker Institute Europe is a leading international charity in the field of person centred care. It supports those working across health and social care systems to use people’s experiences to improve care quality.

Pressure ulcers Sores that develop from sustained pressure on a particular point of the body. Pressure ulcers are more common in patients than in people who are fit and well, as patients are often not able to move about as normal.

Priorities for improvement

There is a national requirement for Trusts to select three to five priorities for quality improvement each year. This must reflect the three key areas of patient safety, patient experience and patient outcomes.

PROMs (Patient Reported Outcome Measures)

PROMs collect information on the effectiveness of care delivered to NHS patients as perceived by the patients themselves. Hospitals providing four key elective surgeries invite patients to complete questionnaires before and after their surgery The PROMs programme covers four common elective surgical procedures: groin hernia operations, hip replacements, knee replacements and varicose vein operations.

Pulmonary Embolism (PE)

A blood clot in the lung.

R

Re-admissions A national indicator. Assesses the number of patients who have to go back to hospital within 30 days of discharge from hospital.

Referral to Treatment Time

Non-emergency NHS consultant-led treatment waiting times; monitors the length of time from referral through to elective treatment.


3Rheumatoid and early inflammatory arthritis

Rheumatoid arthritis is an autoimmune disease that causes inflammation in the joints. The main symptoms are joint pain and swelling. Inflammatory arthritis is a term used to describe a group of conditions which affect the immune system. The body’s defence system starts attacking tissues instead of germs, viruses and other foreign substances, which can cause pain, stiffness and joint damage.

Root Cause Analysis (RCA)

A method of problem solving that looks deeper into problems to identify the root causes and find out why they’re happening.

S

Safety Thermometer The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and ‘harm free’ care. http://www.hscic.gov.uk/thermometer

Secondary Uses Service (SUS)

A national NHS database of activity in Trusts, used for performance monitoring, reconciliation and payments.

Sentinel Stroke National Audit

The Sentinel Stroke National Audit Programme (SSNAP) aims to improve the quality of stroke care by auditing stroke services against evidence-based standards, and national and local benchmarks.

Sepsis A potentially fatal whole-body inflammation (a systemic inflammatory response syndrome) caused by severe infection.

Serious Incidents An incident requiring investigation that results in one of the following:

• Unexpected or avoidable death

• Serious harm

• Prevents an organisation’s ability to continue to deliver healthcare services

• Allegations of abuse

• Adverse media coverage or public concern

• Never events

Shaping a Healthier Future(SaHF)

A programme to improve NHS services for people who live in North West London bringing as much care as possible nearer to patients. It includes centralising specialist hospital care onto specific sites so that more expertise is available more of the time; and incorporating this into one co-ordinated system of care so that all the organisations and facilities involved in caring for patients can deliver high-quality care and an excellent experience.

Sickle Cell Anaemia (Disease)

Sickle cell anaemia is a serious inherited blood disorder where the red blood cells, which carry oxygen around the body, develop abnormally.

Single sex accommodation

A national indicator which monitors whether ward accommodation has been segregated by gender.

SPECT (Single photon emission computed tomography) scanner

SPECT images are obtained following an injection of a radiopharmaceutical that is used for nuclear medicine scans. The injected medication sticks to specific areas in the body, depending on what radiopharmaceutical is used and the type of scan being performed, for example, it will show bone for a bone scan, and gall bladder and bile ducts for a hepatobiliary scan.

Statutory Statutory means ‘by law’.

Streamlining for London Programme

Collaboration between HR for London, NHS Employers and Skills for Health. The focus is on bringing people together to compare performance, share best practices, overcome issues and work collectively to drive change that leads to improved efficiency and patient safety.


Summary Hospital-level Mortality Indicator (SHMI)

The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which reports on mortality at Trust level across the NHS in England. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.

T

TTAs – Tablets to take away

Medication that is to be taken home on a patient’s discharge from hospital.

V

Venous thromboembolism (VTE)

An umbrella term to describe venous thrombus and pulmonary embolism.Venous thrombus is a blood clot in a vein (often leg or pelvis) and a pulmonary embolism is a blood clot in the lung. There is a national indicator to monitor the number of patients admitted to hospital who have had an assessment made of the risk of them developing a VTE

W

WHO (World Health Organisation) Safe Surgery checklist

The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anaesthesia (“sign in”), before the incision of the skin (“time out”) and before the patient leaves the operating room (“sign out”). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation.

Whole Systems Integrated Care (WSIC)

The Whole Systems Integrated Care programme aims to improve the quality and experience of care for patients and service users, save money across the local health and social care system, and enhance professional experience by helping people in health and social care work more effectively together.

Languages/ Alternative Formats

Please call the Patient Advice and Liaison Service (PALS) if you require this information in

other languages, large print or audio format on: 01895 279973. www.thh.nhs.uk


6

4Annual Accounts 2015/16


4.1Statement of the Chief Executive’s Responsibilities as the Accounting Officer


4.1The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by Monitor.

Under the NHS Act 2006, Monitor has directed The Hillingdon Hospitals 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 The Hillingdon Hospitals 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;

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

> Prepare the financial statements on a going concern basis.

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

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor’s NHS Foundation Trust Accounting Officer Memorandum.



5 Statement of Directors’ Responsibilities in Respect of the Accounts


5position of the Trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned direction of the Secretary of State. They are also responsible for safeguarding the assets of the Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

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

STATEMENT OF DIRECTORS’ RESPONSIBILITIES IN RESPECT OF THE ACCOUNTS

The Directors are required under the National Health Services Act 2006 to prepare accounts for each financial year. Monitor, with the approval of the Secretary of State, directs that these accounts give a true and fair view of the state of affairs of the Trust and of the Statements of Comprehensive Income, Financial Position, Tax Payers Equity, Cash Flow and all disclosure notes in the Annual Accounts.In preparing these accounts, Directors are required to:

> Apply on a consistent basis accounting policies according to the NHS Foundation Trust Annual Reporting Manual 2015/16 with the approval of the Secretary of State

> Make judgements and estimates which are reasonable and prudent

> State where applicable accounting standards have been followed, subject to any material departures disclosed and explained in the accounts;

> Comply with International Financial Reporting Standards.

The Directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial


6 Independent Auditor’s Report


6Independence

We are required to comply with the Financial Reporting Council’s Ethical Standards for Auditors and we confirm that we are independent of the Trust and we have fulfilled our other ethical responsibilities in accordance with those standards. We also confirm we have not provided any of the prohibited non-audit services referred to in those standards.

Our assessment of risks of material misstatement

The assessed risks of material misstatement described overleaf are those that had the greatest effect on our audit strategy, the allocation of resources in the audit and directing the efforts of the engagement team.

INDEPENDENT AUDITOR’S REPORT TO THE BOARD OF GOVERNORS AND BOARD OF DIRECTORS OF THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST

Opinion on financial statements of The Hillingdon Hospitals NHS Foundation Trust

In our opinion the financial statements:

> give a true and fair view of the state of the Trust’s affairs as at 31 March 2016 and of its income and expenditure for the year then ended;

> have been properly prepared in accordance with the accounting policies directed by Monitor – Independent Regulator of NHS Foundation Trusts; and

> have been prepared in accordance with the requirements of the National Health Service Act 2006.

The financial statements comprise the Statement of Comprehensive Income, the Statement of Financial Position, the Statement of Cash Flows, the Statement of Changes in Taxpayers’ Equity and the related notes 1 to 31. The financial reporting framework that has been applied in their preparation is applicable law and the accounting policies directed by Monitor – Independent Regulator of NHS Foundation Trusts.

Certificate

We certify that we have completed the audit of the accounts in accordance with the requirements of Chapter 5 of Part 2 of the National Health Service Act 2006 and the Code of Audit Practice.

Going concern

We have reviewed the Accounting Officer’s statement on page 60 that the Trust is a going concern. We confirm that:

> we have concluded that the Accounting Officer’s use of the going concern basis of accounting in the preparation of the financial statements is appropriate; and

> we have not identified any material uncertainties that may cast significant doubt on the Trust’s ability to continue as a going concern.

However, because not all future events or conditions can be predicted, this statement is not a guarantee as to the Trust’s ability to continue as a going concern.


Risk How the scope of our audit responded to the risk

NHS revenue and provisions

There are significant judgments in recognition of revenue from care of NHS patients and in provisioning for disputes with commissioners due to:

• The complexity of the Payment by Results regime, in particular in determining the level of overperformance and Commissioning for Quality and Innovation (“CQUIN”) revenue to recognise

• The judgemental nature of provisions for disputes with commissioners and other counterparties, including in respect of outstanding overperformance income for quarters 3 and 4; and

• The risk of revenue not being recognised at fair value due to adjustments agreed in settling current year disputes and agreement of future year contracts.

The settlement of income with Clinical Commissioning Groups continues to present challenges, leading to disputes and delays in the agreement of year end positions.

The majority of the Trust’s income comes from NHS Hillingdon CCG (15/16: £114m and 14/15 £135.7m) and NHS England (15/16: £18.4m and 14/15: £16.1m), increasing the significance of associated judgements. See note 24 of the financial statements for key related parties and note 1.2 for significant accounting judgements and key sources of estimation and uncertainty. NHS receivables at 31 March 2016 were £20.6m (14/15: £19.9m) of which £6.5m (14/15: £6.3m) were provided against.

We evaluated the design and implementation of controls over recognition of Payment by Results income

We have agreed baseline contract income to underlying contracts and checked a sample of significant year-end income balances to activity data.

We have tested the year-end calculations for partially completed spells and CQUIN income, and evaluated the results of the agreement of balances exercise.

We performed detailed substantive testing of the recoverability of overperformance income and adequacy of provision for underperformance through the year.

We challenged key judgements around specific areas of dispute and actual or potential challenge from commissioners and the rationale for the accounting treatments adopted. In doing so, we considered the historical accuracy of provisions for disputes and reviewed correspondence with commissioners.

Property valuations

The Trust holds property assets within Property, Plant and Equipment at a modern equivalent use valuation. The valuations are by nature significant estimates which are based on specialist and management assumptions and which can be subject to material changes in value.

The value of property assets subject to valuation at 31 March 2016 is £143m (14/15: £136.5m), comprised of land, buildings and dwellings totalling £123.4m (see note 12) and investment properties of £19.6m (see note 14).

We evaluated the design and implementation of controls over property valuations. We considered the qualifications, experience and independence of the valuer.

We assessed whether the valuation was compliant with the relevant accounting standards.

We used Deloitte internal valuation specialists to review the appropriateness of the key assumptions used in the valuation of the Trust’s property assets.


6Risk How the scope of our audit responded to the risk

Management override of controls

We consider that in the current year there is a heightened risk across the NHS that management may override controls to fraudulently manipulate the financial statements or accounting judgements or estimates. This is due to the increasingly tight financial circumstances of the NHS and close scrutiny of the reported financial performance of individual organisations.

All NHS Trusts and Foundation Trusts have been requested by NHS Improvement to consider a series of “technical” accounting areas and assess both whether their current accounting approach meets the requirements of International Financial Reporting Standards, and to remove “excess prudence” to support the overall NHS reported financial position. The areas of accounting estimate highlighted included accruals, deferred income, injury cost recovery debtors, partially completed patient spells, bad debt provisions, property valuations, and useful economic lives of assets.

Details of critical accounting judgements and key sources of estimation uncertainty are included in note 1.2.

Manipulation of accounting estimatesOur work on accounting estimates included considering each of the areas of judgement identified by NHS Improvement. We have reviewed the paper submitted to the Audit Committee on the accounting rationale for the changes in treatment of the items discussed in note 1.2, and have considered both the individual judgements and their impact individually and in aggregate upon the financial statements.

We evaluated the rationale for recognising or not recognising balances in the financial statements and the estimation techniques used in calculations, and considered whether these were in accordance with accounting requirements and were appropriate in the circumstances of the Trust.

Manipulation of journal entriesWe used data analytic techniques to select journals for testing with characteristics indicative of potential manipulation of reporting.

We traced the journals to supporting documentation, considered whether they had been appropriately approved, and evaluated the accounting rationale for the posting. We evaluated individually and in aggregate whether the journals tested were indicative of fraud or bias.

We tested the year-end adjustments made outside of the accounting system between the general ledger and the financial statements.

Going concern

International Accounting Standards and the NHS FT Annual Reporting Manual require Management to assess the Trust’s ability to continue as a going concern. Where Management is aware of material uncertainties in respect of events or conditions that cast significant doubt upon the going concern ability of the NHS Foundation Trust, these should be disclosed in the financial statements.

The deficit at 31 March 2016 of £1.5m (14/15: £6.1m deficit) and increasing pressure on bed capacity and delivery of cost improvement plans has increased our focus on the ability of the Trust to continue as a going concern.

We have reviewed and challenged Management’s going concern assessment, financial plans and forecasts; including sensitivity analysis and actions available to address issues arising.

We have reviewed the Trust’s available cash flow forecasts to the end of 2017/18, and a review of the Trust’s financial plan for 2016/17 including the level and achievability of the CIPs, and any relevant agreement of capital and revenue funding from Monitor and the Department of Health.


Our report includes an additional risk, management override of controls, which was not included in our report last year. This was identified as a risk in 2014/15, but has had an increased effect upon the conduct of our audit this year due to the increased focus upon reported financial position and estimates and estimation techniques.

The description of risks above should be read in conjunction with the significant issues considered by the Audit Committee discussed in section 4 of the Annual Governance Statement on page 64.

These matters were addressed in the context of our audit of the financial statements as a whole, and in forming our opinion thereon, and we do not provide a separate opinion on these matters.

Our application of materiality

We define materiality as the magnitude of misstatement in the financial statements that makes it probable that the economic decisions of a reasonably knowledgeable person would be changed or influenced. We use materiality both in planning the scope of our audit work and in evaluating the results of our work.

We determined materiality for the Trust to be £4.7m (2014/15: £2.2m), which is 2% (2014/15: 1%) of revenue. Revenue was chosen as a benchmark as the Trust is a non-profit organisation, and revenue is a key measure of financial performance for users of the financial statements. We reassessed the percentage used from 1% of revenue in 2014/15 in the context of our cumulative knowledge and understanding the audit risks at the Trust and our assessment of those risks for this year.

We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of £0.2m (2014/15 £0.1m), as well as differences below that threshold that, in our view, warranted reporting on qualitative grounds. We also report to the Audit Committee on disclosure matters that we identified when assessing the overall presentation of the financial statements.

An overview of the scope of our auditOur audit was scoped by obtaining an understanding of the entity and its environment, including internal control. The Trust does not have any subsidiaries and is structured as a single reporting unit and so the whole Trust was subject to the same audit scope. We performed testing at both of the Trust’s sites.

Audit work to respond to the risks of material misstatement was performed directly by the audit engagement team, led by the audit partner. The audit team included integrated Deloitte specialists bringing specific skills and experience in Information Technology systems.

Opinion on other matters prescribed by the National Health Service Act 2006

In our opinion:

> The part of the Directors’ Remuneration Report to be audited has been properly prepared in accordance with the National Health Service Act 2006; and

> The information given in the Performance Report and the Accountability Report for the financial year for which the financial statements are prepared is consistent with the financial statements.

Matters on which we are required to report by exception

Annual Governance Statement, use of resources, and compilation of financial statementsUnder the Code of Audit Practice, we are required to report to you if, in our opinion:

> The Annual Governance Statement does not meet the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual, is misleading, or is inconsistent with information of which we are aware from our audit;

> The NHS Foundation Trust has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources; or

> Proper practices have not been observed in the compilation of the financial statements.

We have nothing to report in respect of these matters.

We are not required to consider, nor have we considered, whether the Annual Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls.


6apparent material misstatements or inconsistencies we consider the implications for our report.

Craig Wisdom ACA Senior Statutory Auditorfor and on behalf of Deloitte LLPChartered Accountants and Statutory AuditorSt Albans, UK26/05/2016

aim to ensure that our quality control procedures are effective, understood and applied. Our quality controls and systems include our dedicated professional standards review team.

This report is made solely to the Board of Governors and Board of Directors (“the Boards”) of The Hillingdon Hospitals NHS Foundation Trust, as a body, in accordance with paragraph 4 of Schedule 10 of the National Health Service Act 2006. Our audit work has been undertaken so that we might state to the Boards those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Trust and the Boards as a body, for our audit work, for this report, or for the opinions we have formed.

Scope of the audit of the financial statements

An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the Trust’s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Accounting Officer; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the annual report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any

Our duty to read other information in the Annual ReportUnder International Standards on Auditing (UK and Ireland), we are required to report to you if, in our opinion, information in the annual report is:

> Materially inconsistent with the information in the audited financial statements;

> Apparently materially incorrect based on, or materially inconsistent with, our knowledge of the Trust acquired in the course of performing our audit;

> Or otherwise misleading.

In particular, we are required to consider whether we have identified any inconsistencies between our knowledge acquired during the audit and the directors’ statement that they consider the annual report is fair, balanced and understandable and whether the annual report appropriately discloses those matters that we communicated to the audit committee which we consider should have been disclosed. We confirm that we have not identified any such inconsistencies or misleading statements.

Respective responsibilities of the accounting officer and auditor

As explained more fully in the Accounting Officer’s Responsibilities Statement, the Accounting Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law, the Code of Audit Practice and International Standards on Auditing (UK and Ireland). We also comply with the International Standard on Quality Control 1 (UK and Ireland). Our audit methodology and tools


7 Foreword and the accounts


7ANNUAL ACCOUNTS 2015/16

Foreword and the accounts

The accounts for the year ended 31 March 2016 have been prepared by the Hillingdon Hospitals NHS Foundation Trust in accordance with paragraphs 24 and 25 of schedule 7 of the National Health Service Act 2006 in the form of which the Independent Regulator of the NHS Foundation Trust (Monitor) has, with the approval of the Secretary of State, directed.

In order to present a true and fair view, the accounts of an NHS Foundation Trust must comply with the International Financial Reporting Standards (IFRS) as adopted by the European Union unless directed otherwise. These accounting standards are published by the International Accounting Standards Board. The Annual Reporting Manual is consistent with these standards which the Trust follows in preparing its accounts. Any departures from these standards are agreed with the external auditors and the Audit and Risk Committee.

Shane DeGarisChief Executive

26th May 2016


STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 MARCH 2016

NOTE 31 March 2016 31 March 2015

£000 £000

Operating Income from patient care operations 3 209,242 194,347

Other operating income 3 29,465 27,482

Total operating income from continuing operations 3 238,707 221,829

Operating expenses of continuing activities 4 (234,592) (225,839)

OPERATING (DEFICIT)/SURPLUS 4,115 (4,010)

FINANCE COSTS

Finance income 8 19 17

Finance expense – financial liabilities 9 (2,084) (2,014)

Finance expense – unwinding of discount on provisions 25 (75) (73)

PDC Dividends payable (3,957) (3,897)

NET FINANCE COSTS (6,097) (5,967)

OTHER NON OPERATING INCOME

Increase in fair value of investment property 10 494 3,874

DEFICIT FOR THE YEAR (1,488) (6,103)

Other comprehensive income

Impairments charged to Reserves 12 – (567)

Revaluations credited to reserves 12 – 12,744

TOTAL COMPREHENSIVE INCOME/(EXPENSE) FOR THE YEAR (1,488) 6,074


7STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2016

NOTE 31 March 2016 31 March 2015

£000 £000

Non-current assets

Intangible Assets 11 2,832 2,980

Property, plant and equipment 12 137,839 136,708

Investment property 14 19,641 19,137

Trade and other receivables 18 840 967

Total non-current assets 161,152 159,792

Current assets

Inventories 17 3,171 2,778

Trade and other receivables 18 19,016 16,790

Cash and cash equivalents 19 4,092 5,483

Total current assets 26,279 25,051

Total assets 187,431 184,843

Current liabilities

Trade and other payables 20 (29,307) (22,427)

Borrowings 21 (3,250) (3,239)

Provisions 25 (125) (957)

Total Current Liabilities (32,682) (26,623)

Net current (liabilities)/assets (6,403) (1,572)

Total assets less current liabilities 154,749 158,220

Non-current liabilities

Borrowings 21 (29,792) (31,804)

Provisions 25 (2,320) (2,314)

Total assets employed 122,637 124,102

Financed by taxpayers’ equity:

Public dividend capital 71,479 71,456

Revaluation reserve 12.2 33,165 33,799

Income and expenditure reserve 17,993 18,847

Total taxpayers’ equity 122,637 124,102


STATEMENT OF CHANGES IN TAXPAYERS’ EQUITY AS AT 31 MARCH 2016

Total Public Dividend Capital

Revaluation Reserve

Income and Expenditure

Reserve

£000 £000 £000 £000

Taxpayers' Equity at 1 April 2015 124,102 71,456 33,799 18,847

Deficit for the year (1,488) – – (1,488)

Transfers between reserves* – – (634) 634

Public dividend capital received 23 23 – –

Taxpayers' Equity at 31 March 2016 122,637 71,479 33,165 17,993

Taxpayers' Equity at 1 April 2014 118,028 71,456 22,362 24,210

Deficit for the year (6,103) – – (6,103)

Transfers between reserves* – – (740) 740

Impairments (567) – (567) –

Revaluations 12,744 – 12,744 –

Taxpayers' Equity at 31 March 2015 124,102 71,456 33,799 18,847

* Transfers between reserves is a depreciation adjustment required due to revaluations of land and buildings.


7STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31 MARCH 2016

NOTE For the Year Ended 31 March 2016

For the Year Ended 31 March 2015

£000 £000

Cash flows from operating activities

Operating (Deficit)/Surplus 4,115 (4,010)

Non-cash income and expense:

Depreciation and amortisation 9,371 8,648

Impairments – 6,933

Gain on disposal 5 0

Receipt of Donated Assets (187) (44)

(Increase)/Decrease in Trade and Other Receivables (1,983) 1,856

(Increase)/Decrease in Inventories (393) 165

(Increase)/Decrease in Trade and Other Payables 7,308 (2,524)

(Decrease)/Increase in Provisions (901) 758

Net cash generated from operations 17,335 11,782

Cash flows from investing activities

Interest received 19 17

Purchase of intangible assets (506) (999)

Purchase of Property, Plant and Equipment Exchequer Financed

(8,618) (13,573)

Net cash used in investing activities (9,105) (14,555)

Cash flows from financing activities

Loans received from the Department of Health – 10,000

Loans repaid to the Department of Health (1,390) (390)

Capital element of finance lease rental payments (1,652) (1,368)

Capital element of LIFT (328) (181)

Interest paid (407) (329)

Interest Element on Finance Lease (276) (286)

Interest Element on LIFT (1,401) (1,399)

Public dividend capital received 23

PDC dividend paid (4,190) (3,523)

Net Cash (Utilised)/Generated from financing activities

(9,621) 2,524

(Decrease) in cash and cash equivalents (1,391) (250)

Cash and Cash equivalents at start of year 5,483 5,733

Cash and Cash equivalents at end of year 19 4,092 5,483


Note 1 Accounting Policies 1.1 Basis of Preparation

Monitor, the Independent Regulator of NHS Foundation Trusts has directed that the financial statements of NHS Foundation Trusts shall meet the accounting requirements of the NHS Foundation Trusts Annual Reporting Manual (FT ARM), as agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the 2015-16 FT ARM. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and the HM Treasury’s Financial Reporting Manual (FReM) to the extent that they are meaningful and appropriate to NHS Foundation Trusts. The particular policies adopted by the Trust are described below. They have been applied consistently in dealing with items considered material in relation to the accounts.

1.2 Accounting judgments and key sources of estimation and uncertainty

In the application of the Trust’s accounting policies management is required to make judgments, estimates, and assumptions about the carrying amount 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 considered of relevance. Actual results may differ from those estimates and underlying assumptions are continually reviewed. Revisions to estimates are recognised in the period in which the estimate is revised, if the revision affects only that period, or in the period of revision and future periods if the revision affects both current and future periods.

The following are the areas where critical judgements have been made in the process of applying accounting policies at the end of the reporting period that have a risk of causing a material adjustment to the carrying amount of assets and liabilities within the next financial year:-

• Going ConcernThe Trust produces an extensive report to the Board outlining all its assumptions on why it believes it is a going concern, and refers to cash forecasts and other reports to back up its solvency predictions. It also refers to the Financial context in which it operates.

• Asset valuation and livesThe Trust conducts regular valuations on its property, utilising specialist third party advisors, and on its equipment. It last conducted a review of its property in March 2015 and of the asset lives of its equipment in March 2016.

• Impairments of receivablesThe Trust regularly reviews the collectability of its debtors to ensure these are appropriately impaired. This assessment is based on the latest cash collection records and other external factors impacting relationships with debtors and the health economy.

• ProvisionsAs at the year end the Trust’s only provision was for staff pensions. It uses actuarial tables provided by the Department of Health in calculating the provision for future payments to pensioners.

• AccrualsThe Trust regularly make evidenced based estimates for income and expenses, where invoices are yet to be raised or received.

The critical judgements are addressed in the accounting policies that follow.

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. 1.3 Going Concern

After making enquiries, the directors have a reasonable expectation that the Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. There is a degree of uncertainty regarding outcomes which may affect incoming resources to the Trust. Readers of these accounts are advised to refer to the Annual Governance Statement of the Trust for more detail. The Trust has produced these accounts on a going concern basis.

1.4 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. 1.5 Current / non-current classification

Assets and liabilities are classified as current if they are expected to be realised within twelve months from the Statement of Financial Position date, the primary purpose of the asset and liability is to be traded, or of loans and receivables where they have a maturity of less than twelve months from the Statement of Financial Position date. All other assets and liabilities are classified as non-current.


71.12 Property, plant and equipment

RecognitionProperty, 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;

• 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.

ComponentisationWhere a large asset, for example a building, includes a number of components with significantly different asset lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives.

ValuationAll property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are

1.6 Consolidation

The Trust’s charitable funds would ordinarily under IAS 27 be considered as a subsidiary entity in that the Hillingdon Hospitals NHS Foundation Trust are corporate trustees and as such exert control over the uses of these funds. The Trust has decided not to consolidate the charitable funds due to the immaterial nature of the balances and instead the summary details are shown by way of a separate note. 1.7 Income Recognition

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 revenue for the Trust is from NHS commissioners for healthcare services.

Where income is received for a specific activity that is to be delivered in the following year, that income is deferred.

Income from the sales 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. 1.8 Partially Completed Spells

The Partial Spells accrual relates to patients who remain undischarged at 31st March 2016. The Trust reflects income at the point of discharge in line with the matching concept. The Trust have accrued income on a per patient basis to 31st March 2016 based on average tariff rates for the speciality. Ordinarily this activity is coded once the patient has been discharged and generated a Health Resource Grouper code to which National Tariff rates are applied to calculate the income. Hence an average tariff is applied based on point of delivery and length of stay by speciality.

1.9 Expenditure on employee benefits

Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees.

1.10 Pensions and other retirement benefits

Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify its 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.

For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the employer.

1.11 Other expenses

Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable.

Expenditure is recognised in operating expenses except where it results in the creation of a non current asset such as property, plant and equipment.


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 end of the reporting period. Fair values are determined as follows:

• Land and non-specialised buildings – market value for existing use

• Investment Properties – market value and or net rental income stream

• Specialised buildings – depreciated replacement cost

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 depreciation commences when they are brought into use.

The last full revaluation exercise took place in the 2014/15 financial year. In line with Treasury guidance, where appropriate the revaluation was based on a Modern Equivalent Assets replacement basis. The valuation was carried out in accordance with the Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation Manual insofar as these terms are consistent with the agreed requirements of the

Department of Health and HM Treasury. The Surveyors were Gerald Eve.LLP.

The Trust carries out a full revaluation exercise at least every five years unless the Trust considers there has been significant market movement In the intervening years.

New fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from fair value.

Subsequent expenditureSubsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably.

Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred.

Depreciation, amortisation and impairmentFreehold land, properties under construction, and assets held for sale are not depreciated.

Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits

or service potential of the assets. The estimated useful life of an asset is the period over which the 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 lease period.

In accordance with the Foundation Trust Annual Reporting Manual (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.

Other impairments are treated as revaluation losses. Reversals of other impairments are treated as revaluation gains.

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.


7the large number of assets involved the Trust has agreed with its auditor to review assets above a net book value of £10k.

1.16 Intangible Assets

RecognitionIntangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the Trust’s business or which arise from contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust and where the cost of the asset can be measured reliably:

• The project is technically feasible to the point of completion and will result in an intangible asset for sale or use;

• The Foundation Trust (FT) intends to complete the asset and sell or use it;

• The FT has the ability to sell or use the asset;

• How the asset will generate probable future economic benefits e.g. the presence of a market for its output or where it is to be used for internal use, the usefulness of the asset;

• Adequate financial, technical, and other resources are available to the FT to complete the development and sell or use the asset during development.

Internally generated intangible assetsInternally generated goodwill, brands, mastheads, publishing titles, customer lists, and similar items are not capitalised as intangible assets, neither is expenditure on research.

an operational asset and the asset’s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs.

1.13 Investment Property

Investment property is property held to earn rentals or for capital appreciation or both. A key factor in determining classification would be whether property was saleable separately. In considering whether land meets this criteria the Trust would consider whether property had direct public access.

Investment property is accounted for under International Accounting Standard 40. A gain or loss arising from a change in the fair value of investment property is recognised in profit or loss for the period in which it arises.

1.14 Donated assets

Donated property, plant and equipment assets are capitalised at their fair value on receipt. The donation is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the donation are to be consumed in a manner specified by the donor, in which case, the donation 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 assets are subsequently accounted for in the same manner as other items of property, plant and equipment.

1.15 Assets no longer in use

The Trust regularly reviews assets not in use for the purpose of revaluing them. The relevant accounting standard affecting this is IFRS 13. The Trust is required to re value any asset found not to be in use to market value or if no market exists, scrap value. Due to

Revaluation Gains, Losses and De-RecognitionRevaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has previously been recognised in operating expenses, in which case they are recognised in operating income.

Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses.

Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of ‘other comprehensive income’.

De-RecognitionAssets intended for disposal are reclassified as ‘Held for Sale’ once all of the following criteria are met: 1) the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; 2) the sale must be highly probable i.e. management are committed to a plan to sell the asset; or an active programme has begun to find a buyer and complete the sale; 3) the asset is being actively marketed at a reasonable price; 4) the sale is expected to be completed within 12 months of the date of classification as ‘Held for Sale’; and the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it.

Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged. Assets are de-recognised when all material sale contract conditions have been met. 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 operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term.

1.18 Local Improvement Finance Trust (LIFT) transactions

HM Treasury has determined that government bodies shall account for infrastructure LIFT schemes where the government body controls the use of the infrastructure and the residual interest in the infrastructure at the end of the arrangement as service concession arrangements, following the principles of the requirements of IFRIC 12. The Trust therefore recognises the LIFT asset as an item of property, plant and equipment together with a liability to pay for it. The services received under the contract are recorded as operating expenses.

The annual lease plus payment is separated into the following component parts, using appropriate estimation techniques where necessary:a. Payment for the fair value of

services received;b. Payment for the LIFT asset,

including finance costs; The Trust is currently party to a 25-year LIFT lease plus contract. Services receivedThe fair value of services received in the year is recorded under the relevant expenditure headings within ‘operating expenses’.

LIFT AssetLIFT assets are recognised as property, plant and equipment, when they come into use. The assets are measured initially at fair value in accordance with the principles of IAS 17. Subsequently, the assets are measured at fair value, which is kept up to date in accordance with the Trust’s approach for each

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 commencement of the lease. Thereafter, the asset is accounted for as an item of property plant and equipment.

The annual rental is split between the repayment of the liability and a finance cost so as to achieve a constant rate of finance over the life of the lease. The annual finance cost is charged to finance costs in the Statement of Comprehensive Income. The lease liability, is de-recognised when the liability is discharged, cancelled or expires.

Operating leasesOther leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease.

Leases of land and buildingsWhere a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. The Trust as LessorRental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging

ImpairmentsAssets that are subject to amortisation are reviewed for impairment whenever events or changes in circumstances indicate that the carrying amount may not be recoverable. Any impairment loss is recognised in the Statement of Comprehensive Income to reduce the carrying amount to the recoverable amount.

SoftwareSoftware which is integral to the operation of hardware e.g. an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software which is not integral to the operation of hardware e.g. application software is capitalised as an intangible asset. MeasurementIntangible assets are recognised initially at cost, comprising of all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management. Subsequently intangible assets are measured at fair value. Revaluation gains and losses and impairments are treated in the same manner as for property, plant and equipment. Intangible assets held for sale are measured at the lower of their carrying amount or ‘fair value less costs to sell.

AmortisationIntangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits:

• Development expenditure up to 5 years

• Software up to 5 years.

1.17 Leases

The Trust as lesseeFinance leases


7clinical negligence cases the legal liability remains with the Trust. 1.23 Non-clinical risk pooling

The 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 excess payable in respect of particular claims are charged to operating expenses as and when they become due.

1.24 Contingencies

A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the Trust, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is not recognised but is disclosed unless the possibility of a payment is remote.

A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the Trust. A contingent asset is not recognised but is disclosed where an inflow of economic benefits is probable.

Where the time value of money is material, contingencies are disclosed at their present value.

amounts of cash with insignificant risk of change in value.

In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the Trust’s cash management.

1.21 Provisions

The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties.

Injury Benefits and Early Retirement: Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury’s discount rates.

From 2012/13 The Treasury publishes three discount rates that are to be employed. These are short term less than 5 years. Medium term 5 to 10 years and long term over 10 years. Where cash flows are expected to fall into more than one on these time frames, then multiple discount rates will need to be used when calculating the carrying value of the provision.

The Trust will continue using its long term rate of 3% as there is no material effect in changing the rate used. The period over which future cash flows will be paid is estimated using the England life expense tables as published by the Office of National Statistics. 1.22 Clinical negligence costs

The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the Trust pays an annual contribution to the NHSLA which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHSLA is administratively responsible for all

relevant class of asset in accordance with the principles of IAS 16.

LIFT liabilityA LIFT liability is recognised at the same time as the LIFT assets are recognised. It is measured initially at the same amount as the fair value of the LIFT assets and is subsequently measured as a finance lease liability in accordance with IAS 17.

An annual finance cost is calculated by applying the implicit interest rate in the lease to the opening lease liability for the period, and is charged to ‘Finance Costs’ within the Statement of Comprehensive Income.

The element of the lease plus payment that is allocated as a finance lease rental is applied to meet the annual finance cost and to repay the lease liability over the contract term.

An element of the lease plus payment increase due to cumulative indexation is allocated to the finance lease. In accordance with IAS 17, this amount is not included in the minimum lease payments, but is instead treated as contingent rent and is expensed as incurred. In substance, this amount is a finance cost in respect of the liability and the expense is presented as a contingent finance cost in the Statement of Comprehensive Income.

1.19 Inventories

Inventories are stated at the lower of cost or net realisable value. Cost is calculated on a FIFO basis (First In First Out).

1.20 Cash and cash equivalents

Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in three months or less from the date of acquisition and that are readily convertible to known


purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the Foundation Trust’s normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs i.e. when receipt or delivery of the goods or services is made.

Financial assets or financial liabilities in respect of assets required or disposed of through finance leases are recognised and measured in accordance with the accounting policy for leases described below.

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 MeasurementFinancial assets are categorised as loans and receivables or available for sale as financial assets.

Financial liabilities are classified as other financial liabilities.

1.31 Loans and receivables

Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. They are included in current assets if receivable in the current reporting period, or in non current assets if outside the current reporting period.

The Trust’s loans and receivables comprise cash and cash equivalents, NHS debtors, accrued income and other debtors.

which work out how much input tax they may recover. The percentage relating to partially exempt supplies is currently 1.25% which reduces the Trust’s VAT recovery. This percentage is reviewed annually.

1.27 Corporation Tax

The Trust is a Health Service body within the meaning of s519A ICTA 1988 and accordingly in relation to specified activities of a Foundation Trust (s519A (3) to (8) ICTA 1988).

None of the Trust’s activities in the period are subject to a corporation tax liability.

1.28 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.

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 expenditure on an accruals basis.

1.30 Financial instruments and financial liabilities

RecognitionFinancial assets and financial liabilities which arise from contracts to the

1.25 Public Dividend Capital (PDC) and PDC dividend

Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS Trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32.

A charge, reflecting the cost of capital utilised by the NHS Foundation Trust, is payable as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS Foundation Trust during the financial year. Average relevant net assets is defined as the average of the opening and closing reserves less the average of the opening and closing net book value of donated assets, less the average cleared/available balance of the Government Banking Service balances over the year. The dividend thus calculated is not revised should any adjustment to net assets occur as a result of the audit of the annual accounts.

1.26 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.

The Trust makes both taxable and exempt supplies and incurs input tax that relates to both kinds of supply. The Trust is therefore classified as ‘partly exempt’. Partly exempt businesses must undertake calculations


7have 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 NHS Foundation Trust has with Clinical Commissioning Groups and the way those Clinical Commissioning Groups are financed, the NHS Foundation Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The NHS Foundation Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the NHS Foundation Trust in undertaking its activities.

The Trust’s treasury management operations are carried out by the finance department, within parameters defined formally within the Trust’s standing financial instructions and policies agreed by the board of directors. Trust treasury activity is subject to review by the Trust’s internal auditor.

Currency riskThe Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Trust has no overseas operations. The Trust therefore has low exposure to currency rate fluctuations.

Interest rate riskTo date, the Trust has only borrowed from UK Government for capital expenditure. The borrowings were for 1-25 years, in line with the life of the

impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.

For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the Statement of Comprehensive Income and the carrying amount of the asset is reduced directly or through the use of a bad debt provision.

1.34 Foreign currencies

The Trust’s functional currency and presentational currency is sterling. 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 recognised in the Trust’s surplus/deficit in the period in which they arise. 1.35 Government Grants

Government grants are grants from Government bodies other than income from Clinical Commissioning Groups or NHS trusts for the provision of services. Where a grant is used to fund revenue or capital expenditure it is taken to the Statement of Comprehensive Income to match that expenditure. The exception to this is where specific grant conditions apply regarding the recognition of income.

1.36 Financial risk management

International Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments

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 net carrying amount of the financial asset.

Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive Income.

1.32 Other financial liabilities

All other financial liabilities are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability.

They are included in current liabilities except for amounts payable more than 12 months after the reporting period, which are reclassified as long-term liabilities.

Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to finance costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets.

1.33 Impairment of financial assets

At the end of the reporting period, the Trust assesses whether any financial assets, other than those held at ‘fair value through profit and loss’ are


expenditure relates to a clearly defined project and the benefits of it can reasonably be regarded as assured. Expenditure so deferred is limited to the value of future benefits expected and is amortised through the Operating Cost Statement on a systematic basis over the period expected to benefit from the project. It should be revalued on the basis of current cost. The amortisation is calculated on the same basis as depreciation, on a quarterly basis.

1.37 Events after the reporting period

Generally accepted accounting principles state that the financial statements should include the effects of all subsequent events that provide additional information about conditions in existence as of the balance sheet date. This rule requires that all entities evaluate subsequent events through the date when financial statements are available to be issued.

There are no post balance sheet events to report.

1.38 Research and Development

Research and development expenditure is charged against income in the year in which it is incurred, except insofar as development

associated assets, and interest charged at the National Loans Fund rate, fixed for the life of the loan. The Trust therefore has low exposure to interest rate fluctuations.

Credit riskBecause the majority of the Trust’s income comes from contracts with other public sector bodies, the Trust has low exposure to credit risk. The maximum exposures as at 31 March 2015 are in receivables from customers, as disclosed in the trade and other receivables note 18. Liquidity riskThe majority of the Trust’s operating costs are incurred under contracts with Clinical Commissioning Groups, which are financed from resources voted annually by Parliament. The Trust is not, therefore, exposed to significant liquidity risks.


7

Change published Published by IASB

Financial year for which the change first applies

IFRS 11 (amendment) – acquisition of an interest in a joint operatiom Fair Value Measurement

May-14 Not yet EU adopted. Expected to be effective from 2016/17

IFRS 16 (amendment) and IAS 38 (amendment) – depreciation and amortisation


IFRS 16 (amendment) and IAS 41 (amendment) – bearer plants

Jun-14 Not yet EU adopted. Expected to be effective from 2016/17

IAS 27 (amendment) – equity method in separate financial statements


IFRS 10 (amendment) and IAS 28 (amendment) – sale or conribution of assets

Aug-14 Not yet EU adopted. Expected to be effective from 2016/17

IFRS 10 (amendment) and IAS 28 (amendment) – investment entities applying the consolidation exception

Sep-14 Not yet EU adopted. Expected to be effective from 2016/17

IAS 1 (amendment) – disclosure initiative Dec-14 Not yet EU adopted. Expected to be effective from 2016/17

IFRS 15 Revenue from contracts with customers May-14 Not yet EU adopted. Expected to be effective from 2016/17

Annual improvements to IFRS: 2012 -2015 cycle Sep-14 Not yet EU adopted. Expected to be effective from 2016/17

IFRS 9 Financial Instruments Jul-14 Not yet EU adopted. Expected to be effective from 2016/17

1.39 Accounting standards and amendments issued but not yet adopted in the ARM

The following new and revised standards and interpretations were in issue but not yet adopted in the ARM. None of these new and revised standards and interpretations have been adopted early by the Trust. The Trust do not expect that the adoption of the standards listed in the table below will have a material impact on the financial statements of the Trust in future periods.


Note 2 Segmental Analysis

Surgical Division

Medical Division

Women & Children’s

Division

Cancer & Clinical

Support Services

Corporate Division

Unallocated Income

Total

31 March 2016

31 March 2016

31 March 2016

31 March 2016

31 March 2016

31 March 2016

31 March 2016

(£’000) (£’000) (£’000) (£’000) (£’000) (£’000) (£’000)

NHS Clinical Income 59,028 82,192 40,163 24,208 205,591

Non NHS Clinical Income 1,368 433 261 1,621 3,683

Other Income 2,563 2,212 1,471 2,075 12,473 20,794

Unallocated Income 8,639 8,639

Total Operating Revenue 62,959 84,837 41,895 27,904 12,473 8,639 238,707

Pay (35,715) (43,539) (20,797) (29,137) (26,825) (156,013)

Non Pay (13,308) (16,814) (2,963) (12,570) (22,583) (68,238)

Internal Recharges (2,415) (2,529) (922) 5,850 (27) (43)

Unallocated Expenses (921) (921)

Total Operating Expenditure before Depreciation, Impairments and Interest (51,438) (62,882) (24,682) (35,857) (49,435) (921) (225,215)

Earnings before Interest, Taxation, Depreciation and Amortisation 11,521 21,955 17,213 (7,953) (36,962) 7,718 13,492

Allocated Depreciation & Amortisation

(451) (299) (43) (508) (633) (1,934)

Unallocated Depreciation & Amortisation

(7,438) (7,438)

Unallocated Impairments (5) (5)

Operating Surplus/(Deficit) 11,070 21,656 17,170 (8,461) (37,595) 275 4,115


7Note 2 Segmental Analysis (continued)

Surgical Division

Medical Division

Women & Children’s

Division

Cancer & Clinical

Support Services

Corporate Division

Unallocated Income

Total

31 March 2015

31 March 2015

31 March 2015

31 March 2015

31 March 2015

31 March 2015

31 March 2015

(£’000) (£’000) (£’000) (£’000) (£’000) (£’000) (£’000)

NHS Clinical Income 61,208 76,274 34,187 18,638 – 190,307

Non NHS Clinical Income 1,116 707 305 1,907 5 4,040

Other Income 2,405 2,249 1,277 2,264 11,703 19,898

Unallocated Income 7,584 7,584

Total Operating Revenue 64,729 79,230 35,769 22,809 11,708 7,584 221,829

Pay (33,023) (39,945) (19,058) (26,653) (25,072) (143,751)

Non Pay (13,809) (13,736) (2,685) (12,108) (20,644) (62,982)

Internal Recharges (2,334) (2,316) (850) 5,479 21 0

Unallocated Expenses – – – – – (3,525) (3,525)

Total Operating Expenditure before Depreciation, Impairments and Interest (49,166) (55,997) (22,593) (33,282) (45,695) (3,525) (210,258)

Earnings before Interest, Taxation, Depreciation and Amortisation 15,563 23,233 13,176 (10,473) (33,987) 4,059 11,571

Allocated Depreciation & Amortisation

(419) (226) (28) (354) (565) (1,592)

Unallocated Impairments – – – – – (7,056) (7,056)

Unallocated Impairments – – – – – (6,933) (6,933)

Operating Surplus/(Deficit) 15,144 23,007 13,148 (10,827) (34,552) (9,930) (4,010)

The only activity of the NHS Foundation Trust is Healthcare and its primary customer is NHS Hillingdon CCG. However, segmental information has been included on the basis the following information is reported regularly to the Chief Executive for the purpose of allocating resources to that segment and assessing its performance. Transactions between divisions would reflect the re-allocation of shared costs. All services relating to transactions shown below were provided to external customers of the Trust. .

Segmental net assets are not recorded as part of the internal reporting process and as such are not disclosed.

The reportable segments are different operational divisions within the Trust, which provide different groups of service. They are managed separately as they involve different medical disciplines and patient groups. Segments have not been aggregated

The major external customer is NHS Hillingdon CCG which accounted for revenue of £136,701k and features in all segments. No other customer accounted for more than 7.25% of revenue.

The split of Clinical Income in 2014-15 has been restated so that it is comparable with 2015-16.


Note 3 Operating Income

Note 3.1 Operating income (by nature) 31 March 2016 31 March 2015

Income From Activities £000 £000

Acute Trusts

NHS Clinical Income

Elective income 29,200 32,053

Non elective income 61,184 60,620

Outpatient income 55,354 50,984

A & E income* 8,365 7,844

Other NHS clinical income 51,488 38,806

All Trusts

Private patient income 193 224

Other clinical income 3,458 3,816

Total income from activities 209,242 194,347

Total other operating income 29,465 27,482

Total Operating Income 238,707 221,829

Note 3.2 Operating lease income 31 March 2016 31 March 2015

£000 £000

Operating Lease Income

Rents recognised as income in the year 1,683 1,611

Contingent rents recognised as income in the year 535 1,812

TOTAL 2,218 3,423

Future minimum lease payments due

on leases of Land expiring

- not later than one year; 1,321 1,321

- later than one year and not later than five years; 5,283 5,283

- later than five years. 91,131 92,451

sub total 97,735 99,055

on leases of Buildings expiring

- not later than one year; 318 214

- later than one year and not later than five years; 981 658

- later than five years. 1,889 148

sub total 3,188 1,020

TOTAL 100,923 100,075

Leasing arrangements are all with bodies external to the UK Government.

Leasing arrangements relate significantly to land rental on both the Hillingdon and Mount Vernon sites.


7Note 3.3 Operating Income 31 March 2016 31 March 2015

£000 £000

Income from activities

NHS Foundation Trusts 118 117

NHS Trusts 660 –

CCGs and NHS England* 204,813 190,191

Local Authorities 1,400 1,669

Non NHS: Private patients 193 224

Non-NHS: Overseas patients (non-reciprocal) 894 882

NHS injury scheme (formerly RTA) 985 919

Non NHS: Other 179 345

Total income from activities 209,242 194,347

Other operating income

Research and development 625 719

Education and training 8,901 9,044

Grants and Donations 187 44

Non-patient care services to other bodies 8,875 8,002

Rental revenue from operating leases – minimum lease receipts 1,683 1,611

Rental revenue from operating leases – contingent rent 535 1,812

Other** 8,415 6,062

Income in respect of staff costs where accounted on gross basis 244 188

Total other operating income 29,465 27,482


*Income from Commissioner requested Services

Commissioner Requested Services 204,813 190,191

Other Services 33,894 31,638


** Analysis of Other Operating Income: Other

Car parking 1,665 1,762

Estates recharges 387 273

Pharmacy sales 53 99

Staff accommodation rentals 154 107

Clinical tests 41

Clinical excellence awards 187 247

Catering 1,225 996

Property rentals 715 533

Other 3,988 2,045

Total 8,415 6,062


Note 3.4 Overseas visitors (relating to patients charged directly by the foundation trust)

31 March 2016

31 March 2015

£000 £000

Income recognised this year 894 882

Cash payments received in-year (relating to invoices raised in current and previous years) 489 600

Amounts added to provision for impairment of receivables (relating to invoices raised in current and prior years)

(102) (9)

Amounts written off in-year (relating to invoices raised in current and previous years) 131 263


7Note 4 Operating Expenses

2014-15 2014-15£000 £000

Services from NHS Foundation Trusts 1,281 1,063 Services from NHS Trusts 148 200 Employee Expenses – Executive directors 1,054 1,075 Employee Expenses – Non-executive directors 131 135 Employee Expenses – Staff 155,439 143,055 Supplies and services – clinical (excluding drug costs) 9,799 8,990 Supplies and services – general 2,101 1,876 Establishment 4,914 4,443 Transport – business travel 175 120 Transport – other 1,364 1,223 Premises – Business rates payable to Local Authorities 893 688 Premises – Other 6,360 6,536 Increase in provision for impairment of receivables 324 978 (Decrease)/Increase in provisions* (494) 925 Inventories written down (net, including inventory drugs) 50 82 Drugs costs (non inventories) 1,327 1,085 Inventories consumed (excluding drugs) 16,183 16,028 Drugs inventories consumed 16,654 14,383 Rentals under operating leases – minimum lease receipts 304 304 Rentals under operating leases – contingent rent 9 4 Depreciation on property, plant and equipment 8,717 8,162 Amortisation on intangible assets 654 486 Impairments of property, plant and equipment - 6,933 Audit services – Financial Statements 81 76 Audit services – Quality Accounts 17 17 Clinical negligence – amounts payable to the NHSLA (premiums) 3,997 4,121 Loss on disposal of other property, plant and equipment 5 - Legal fees 223 160 Consultancy costs 160 62 Internal audit costs 148 130 Training, courses and conferences 880 733 Patient travel 3 4 Car parking & Security 101 156 Redundancy – (Included in employee expenses) - 109 Hospitality 28 29 Insurance 253 227 Other services 1,220 1,156 Losses, ex gratia & special payments – (Not included in employee expenses) 44 38 Other 45 47 TOTAL OPERATING EXPENSES 234,592 225,839

* The provision credit relates to (1) a (£555k) credit due to a reversal of an unused tax and NI provision and (2) a charge arising in the year in the Pensions Provision of £61k which nets off to the £494k credit.

All expenses above related to continuing operations.


Note 5 Operating lease Expenditure Payments recognised as an expense 31 March 2015 31 March 2015

£000 £000

Minimum lease payments 304 304

Contingent rents 9 4

313 308

Total future minimum lease payments 31 March 2015 31 March 2015

£000 £000

Payable:

Not later than one year 314 311

Between one and five years 1,258 1,245

Later than five years. 786 1,090

Total 2,358 2,646

The Trust is party to a ten year lease agreement for a modular healthcare building on the Hillingdon Hospital site ending October 2023.


7Note 6 Employee costs and numbers

6.1 Employee costs Total 31 March 2016 Permanently

employed

Other Total 31 March 2015 Permanently

employed

Other

£000 £000 £000 £000 £000 £000 Salaries and wages 120,264 113,483 6,781 111,147 105,159 5,988 Social security costs 10,403 10,006 397 9,721 9,337 384 Employer contributions to NHS Pension scheme

13,621 13,223 398 12,158 11,822 336

Termination benefits - - - 132 132 - Agency/contract staff 14,725 - 14,725 13,623 - 13,623 Less Salary Costs Recharged to Other Organisations

(1,465) (1,465) - (1,336) (1,336) -

Employee benefits expense 157,548 135,247 22,301 145,445 125,114 20,331

Of the total above: Charged to capital 1,055 965 90 1,206 1,111 95 Charged to revenue 156,493 134,282 22,211 144,239 124,003 20,236

157,548 135,247 22,301 145,445 125,114 20,331

6.2 Directors aggregate remuneration 31 March 2016 31 March 2016 31 March 2015 31 March 2015

Remuneration Number of Remuneration Number of

£000 Directors ** £000 Directors **

Executive Directors 1,054 9 1,075 9

Non Executive Directors* 131 7 135 9

Total** 1,185 16 1,210 18

**Analysis of Directors Remuneration (£000)

Gross pay 969 998

Employer Pension Contributions 104 97

Employer National Insurance Contributions 112 115

Total 1,185 1,210

*Non Executive Directors are not members of the NHS pension scheme.

** The number of directors denotes the number of individuals employed in a director position at some point during the financial year, not the number of directors simultaneously employed.


6.3 Average number of people employed

Total 31 March 2016 Permanently

employed

Other Total 31 March 2015 Permanently

employed

Other

Number Number Number Number Number Number Medical and dental 460 438 22 433 420 13 Administration and estates 748 689 59 733 682 51 Healthcare assistants and other support staff 637 503 134 590 441 149 Nursing, midwifery and health visiting staff

955 808 147 871 722 149

Scientific, therapeutic and technical staff 316 286 30 292 254 38 Healthcare science staff 153 136 17 123 117 6 Total 3,269 2,860 409 3,042 2,636 406

Of the above: Number of whole time equivalent staff engaged on capital projects 16 15 1 20 20 -

6.4 Early Retirements due to ill health 31 March 2016 31 March 2015

Number Number

There were five early retirements on the grounds of ill-health during 2015/16 (Prior year nil)

5 -

The cost of early retirement due to ill health is borne by the NHS Business Services Authority who administer NHS pensions.


76.5 Exit Packages

31 March 2016

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

Number £000s Number £000s Number £000s

<£10,000 - - 3 10 3 10

Total - - 3 10 3 10

6.6 Exit Packages

31 March 2015

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

Number £000s Number £000s Number £000s

<£10,000 - - 1 6 1 6

£10,001 – £25,000 - - 1 17 1 17

£100,001 - £150,000 1 109 - - 1 109

Total 1 109 2 23 3 132

Exit packages: other (non-compulsory) departure payments

2015-16 2015-16 2014-15 2014-15

Agreed number

Total value of agreements

Agreed number

Total value of agreements

£000 £000

Contractual payments in lieu of notice 3 10 2 23

Total 3 10 2 23

6.7 Staff sickness absence 31 March 2016 31 March 2015

Number Number

Total days lost 37,242 34,627

Total staff years* 2,965 2,750

Average working days lost 13 13

*Staff years is a calculation based on the number of working days of full time and part time staff employed by the Trust converted into composite staff years.


Note 7 Better Payment Practice Code

7.1 Better Payment Practice Code – measure of compliance 31 March 2016 31 March 2015

Number £000 Number £000

Total Non-NHS trade invoices paid in the year 88,988 89,926 88,903 98,243

Total Non NHS trade invoices paid within target 51,025 48,847 43,047 51,990

Percentage of Non-NHS trade invoices paid within target 57% 54% 48% 53%

Total NHS trade invoices paid in the year 2,633 9,366 2,951 10,606

Total NHS trade invoices paid within target 1,363 5,592 1,174 4,929

Percentage of NHS trade invoices paid within target 52% 60% 40% 46%

The Better Payment Practice Code requires the Trust to aim to pay all undisputed invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later.

7.2 The Late Payment of Commercial Debts (Interest) Act 1998 31 March 2016 31 March 2015

£000 £000

Amounts included in finance costs from claims made under this legislation 3 10

Note 8 Finance income 31 March 2016 31 March 2015

£000 £000

Interest on bank accounts 19 17

Note 9 Finance expenses 31 March 2016 31 March 2015

£000 £000

Interest expense:

Interest paid on Finance leases 276 286

Interest on late payment of commercial debt 3 10

Interest paid on Capital loans from the Department of Health 240 254

Interest due on Working Capital loans from the Department of Health 164 65

Interest on LIFT contract 1,401 1,399

Total 2,084 2,014


7

Note 11 Intangible Assets 31 March 2016 31 March 2015

£000 £000

Cost brought forward at 1st April 2014 5,907 4,582

Other Reclassifications - 326

Additions – purchased 506 999

Cost at 31 March 2016 6,413 5,907

Amortisation Brought Forward at 1st April 2014 2,927 2,441

Amortisation provided in Year 654 486

Amortisation at 31 March 2015 3,581 2,927

Net Book Value at 31 March 2015 2,832 2,980

Intangible Assets consists of Software licences

Note 10 Other non-operating income 31 March 2016 31 March 2015

£000 £000

Increase in fair value of investment property 494 3,874


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12.2 Revaluation reserve balance for property, plant & equipment

Total

Current Year £000

At 1 April 2015 33,799

Depreciation adjustment* (634)

At 31 March 2016 33,165

Total

Previous Year £000

As at 1 April 2014 22,362

Depreciation adjustment* (740)

Impairments (567)

Revaluations 12,744

At 31 March 2015 33,799

* Transfers between reserves is a depreciation adjustment required due to revaluations of land and buildings.


713.1 Economic lives of property, plant and equipment

Min life Max life

Years Years

Intangible assets – internally generated

Information technology 5 15

Intangible assets – purchased

Software 5 15

Licences & trademarks 5 15

13.2 Economic lives of property, plant and equipment

Min life Max life

Years Years

Buildings exc Dwellings 2 60

Dwellings 5 5

Plant and Machinery 5 15

Transport equipment 5 5

Information Technology 5 15

Furniture and Fittings 5 15

Note 14 Investment Property 31 March 2016 31 March 2015

£000 £000

Balance at Beginning of year 19,137 14,816

Recclassification from Operational Buildings 10 447

Net gain from Fair Value Adjustments 494 3,874

Balance at End of Year 19,641 19,137

Income from Occupied Investment Properties 1,950 2,667

Expenses of Investment Properties (1,028) (1,021)

Surplus 922 1,646

Expenses of unoccupied Investment Properties 3 3

15 Impairment of assets 31 March 2016 31 March 2015

£000 £000

Changes in market price. Operating Expenses - 6,933

Changes in market price. Revaluation Reserve - 567

Total Gross Impairments - 7,500


Note 17 Inventory Movement Total Drugs Consumables Energy Other

Current Year £000 £000 £000 £000 £000

Carrying Value at 1st April 2015 2,778 877 1,722 48 131

Additions 33,280 16,859 14,384 - 2,037

Inventories recognised as expenses (32,837) (16,654) (14,150) - (2,033)

Write-down of inventories recognised as an expense (50) (46) (4) - -

Carrying Value at 31st March 2016 3,171 1,036 1,952 48 135

Total Drugs Consumables Energy Other

Prior Year £000 £000 £000 £000 £000

Carrying Value at 1st April 2014 2,943 1,123 1,673 11 136

Additions 28,432 14,180 14,004 38 210

Inventories recognised as expenses (28,515) (14,383) (13,916) (1) (215)

Write-down of inventories recognised as an expense (82) (43) (39) - -

Carrying Value at 31st March 2015 2,778 877 1,722 48 131

Note 16 Capital Commitments 31 March 2016 31 March 2015

£000 £000

Property, plant and equipment 4,465 1,063


718.1 Trade and other receivables 31 March 2016 31 March 2015

£000 £000

Current

NHS receivables – revenue 18,306 17,902

NHS receivables – accrued income 1,643 1,212

NHS provision for credit notes (6,069) (6,323)

Sub Total NHS 13,880 12,791

Prepayments 1,909 1,662

PDC dividend receivable 116 -

VAT receivable 416 665

Other receivables 4,208 2,993

Provision for impaired receivables (1,513) (1,321)

Total current trade and other receivables 19,016 16,790

Non-Current

Other receivables 1,077 1,192

Less Provision for impaired receivables (237) (225)

Total non-current trade and other receivables 840 967

18.2 Provision for impairment of receivables 31 March 2016 31 March 2015

£000 £000

At 1 April 1,546 828

Increase in provision 324 978

Amounts Utilised (120) (260)

At end of year 1,750 1,546

18.3 Ageing of impaired receivables 31 March 2016 31 March 2015

£000 £000

0 – 30 days 58 92

30 – 60 days 59 621

60 – 90 days 58 92

90 – 180 days 132 251

over 180 days 1,443 490

Total 1,750 1,546

18.4 Ageing of non-Impaired receivables past their due date 31 March 2016 31 March 2015

£000 £000

0 – 30 days 1,329 3,941

30 – 60 days 1,191 3,078

60 – 90 days 915 810

90 – 180 days 4,244 2,393

over 180 days 5,907 5,392

Total 13,586 15,614


Note 19 Cash and cash equivalents31 March 2016 31 March 2015

£000 £000

Balance at 1 April 5,483 5,733

Net decrease in year (1,391) (250)

Balance at end of Year 4,092 5,483

Made up of

Cash with Government banking services 2,866 4,658

Commercial banks and cash in hand 1,226 825

Cash and cash equivalents as in statement of financial position 4,092 5,483

Cash and cash equivalents as in statement of cash flows 4,092 5,483

Note 20 Trade and other payables 31 March 2016 31 March 2015

£000 £000

Current

Receipts in advance 3,604 2,163

NHS payables – revenue 2,963 1,600

Pensions 1,967 1,791

Other trade payables – capital 806 1,117

Other trade payables – revenue 8,299 4,271

Social Security costs 3,060 2,968

Other payables 330 167

PDC dividend payable - 227

Accruals and deferred income 8,278 8,123

Total Trade and Other payables 29,307 22,427


721 Borrowings 31 March 2016 31 March 2015

£000 £000

Current

Capital loans from Department of Health 390 390

Working capital loan from Department of Health 1,000 1,000

Obligations under finance leases 1,644 1,521

Obligations under LIFT contracts 216 328

Total current borrowings 3,250 3,239

Non-current

Capital loans from Department of Health 5,905 6,295

Working capital loan from Department of Health 8,000 9,000


Obligations under LIFT contracts 12,174 12,390

Total non current borrowings 29,792 31,804

The Trust is party to three Department of Health loans as follows:

- Loan 1 (for capital investment) received 15th December 2009 for £4.0m. Repayments commenced on 15th March 2010 and will continue until 15th September 2034. The loan carries a fixed interest rate at 4.11%.

- Loan 2 (for capital investment) received 15th September 2010 for £4.6m. Repayments commenced on 15th March 2011 and will continue until 15th September 2030. The loan carries a fixed interest rate at 3.25%.

- Loan 3 (for working capital) received 16th November 2014 for £10.0m. Repayments commence on 17th May 2015 and will continue until 15th November 2024. The loan carries a fixed interest rate at 1.74%.


Note 22 Finance lease liabilitiesThe lease arrangements relate to a number of equipment leases which vary in length from three to seven years.

All leases are with bodies external to government. Details of the accounting for finance leases can be found in

note 1 – accounting policies..

Amounts payable under finance leases

Gross lease liabilities 31 March 2016 31 March 2015

£000 £000

Within one year 1,867 1,771


Later than five years 142 215

Sub total gross finance lease liabilities 5,904 6,200

Future Finance Charges (547) (560)

Total net finance lease liabilities 5,357 5,640

Net lease liabilities 31 March 2016 31 March 2015

£000 £000

Within one year 1,644 1,521


Later than five years 132 203

Total net finance lease liabilities 5,357 5,640


7Note 23 NHS Local Improvement Finance Trust (LIFT) contract The LIFT agreement is for a 25 year period which commenced in December 2008. The scheme is for the provision

of clinical accommodation on the Mount Vernon Hospital site which comprises four surgical theatres and

outpatient suites. The annual lease payment (inclusive of interest, capital and services) is £1,557k per annum. The

LIFT agreement is with a body external to government. Details of the accounting for the LIFT contract can be found

in note 1 – accounting policies.

23.1 LIFT liabilities

Finance lease obligations payable under the LIFT contract

Gross LIFT liabilities 31 March 2016 31 March 2015

£000 £000

Not later than one year 1,088 1,221

Later than one year, not later than five years 4,287 4,371

Later than five years 19,096 20,099

Sub total gross LIFT liability 24,471 25,691

Future Finance Charges (12,081) (12,973)

Total net LIFT liability 12,390 12,718

Net LIFT liabilities 31 March 2016 31 March 2015

£000 £000

Not later than one year 216 328

Later than one year, not later than five years 960 924


Total net LIFT liability 12,390 12,718

23.2 Total Future Commited Expenditure in respect of LIFT

The Trust is committed to the following service charge payments over the life of the LIFT scheme:-

LIFT projected future expenditure 31 March 2016 31 March 2015

£000 £000

Not later than one year 1,557 1,557

Later than one year, not later than five years 6,228 6,228


Total 32,445 34,002

23.3 Payments in year to Operator in respect of LIFT

The Trust paid the following amounts during the year in respect of LIFT

LIFT expenditure 31 March 2016 31 March 2015

£000 £000

Interest charge 1,401 1,399

Repayment of finance lease liability 328 181

Service element 336 467

Total 2,065 2,047


Note 24 Related party transactions During the year none of the Trust board members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with The Hillingdon Hospitals NHS Foundation Trust. The United Kingdom Government is regarded as a related party to the extent that it controls the Department of Health and National Health Organisations through legislation and funding by the taxpayer. During the year The Hillingdon Hospitals NHS Foundation Trust has had a significant number of material transactions with the Department, and with other NHS entities as well as directly with the UK Government. These transactions are itemised below subject to a minimum of £100k for transactions and balances for the year to 31st March 2016. These limits are in accordance with the Agreement of balances exercise for Whole Government Accounts.


724.1 Balances Current

Receivables as at

31 March 2016

Current Receivables

as at 31 March 2015

Current Payables

as at 31 March 2016

Current Payables

as at 31 March 2015

Entities £000s £000s £000s £000s

Central And North West London MH NHS Foundation Trust 215 – 515 –

Royal Brompton And Harefield NHS Foundation Trust 60 – 193 –

Royal Free London NHS Foundation Trust 71 – 300 –

University College London 1 - 142 -

East And North Hertfordshire NHS Trust 2,280 3,893 144 7

Imperial College Healthcare NHS Trust 189 87 706 311

NHS Ealing 3,042 1,262 - –

London North West Healthcare NHS Trust 1,078 810 234 81

NHS Barnet CCG 222 – - –

NHS Brent CCG 363 – - 244

NHS Central London (Westminster) CCG 456 226 - –

NHS Harrow CCG 895 986 - –

NHS Herts Valleys CCG 237 – - –

NHS Hillingdon CCG 6,858 7,868 296 128

NHS Hounslow CCG 1,129 281 - –

NHS North West Surrey CCG 150 – - –

NHS Slough CCG - 438 - –

NHS England 499 431 - –

Department of Health (PDC dividend only) 116 – - 227

Other NHS (Balances below £100k) 2,328 2,832 433 829

Central and Local Government 499 819 5,029 4,759

Total Related Parties Balances 20,688 19,933 7,992 6,586


24.2 Transactions Revenue Year to 31 March 2016

Revenue Year to 31 March 2015

Expenditure Year to 31 March 2016


Entities £000s £000s £000s £000s

Royal Free London NHS Foundation Trust 247 241 597 262

Central And North West London MH NHS Foundation Trust 900 970 1,075 767

Frimley Heath - - 120 -

N E London - - 103 -

Kings College Hospital NHS Foundation Trust - - 171 -

Royal Brompton And Harefield NHS Foundation Trust 526 521 459 271

East And North Hertfordshire NHS Trust 9,075 6,228 351 393

Imperial College Healthcare NHS Trust 440 473 866 748

Health Education England 9,203 9,439 2 -

London North West Healthcare NHS Trust 1,233 954 584 228

NHS Aylesbury Vale CCG 124 129 - -

NHS Barnet CCG 261 206 - -

NHS Bracknell and Ascot CCG 110 - - -

NHS Brent CCG 1,141 2,434 - -

NHS Camden CCG 115 - - -

NHS Central London (Westminster) CCG 971 511 - -

NHS Dorset CCG 118 - - -

NHS Chiltern CCG 3,533 3,402 - -

NHS Ealing CCG 21,097 15,249 - -

NHS East and North Hertfordshire CCG 189 - - -

NHS England 18,138 16,109 - -

NHS Hammersmith And Fulham CCG 570 512 - -

NHS Haringey CCG 104 - - -

NHS Harrow CCG 7,211 7,734 - -

NHS Herts Valleys CCG 5,044 4,707 - 127

NHS Hillingdon CCG 142,969 135,657 - -

NHS Hounslow CCG 4,363 3,687 - -

NHS Litigation Authority - - 4,146 4,360

NHS Luton CCG 107 - - -

NHS North West Surrey CCG 296 181 - -

NHS Richmond CCG 128 - - -

NHS Slough CCG 619 586 - -


724.2 Transactions Revenue Year to

31 March 2016Revenue Year to

31 March 2015Expenditure Year to 31 March 2016


NHS West London (K&C & Qpp) CCG 194 140 - -

NHS Windsor, Ascot And Maidenhead CCG 312 393 - -

West Hertfordshire Hospitals NHS Trust 113 107 51 53

Other NHS 2,622 3,006 908 1,522

Total NHS 232,073 213,576 9,433 8,731

Central and Local Government 1,459 1,563 23,819 22,968

Total Whole Government Accounts (WGA) 233,532 215,139 33,252 31,699

Non WGA Entities*

British Telecommunications plc - - 120 297

Other non WGA entities - - - 14

Total Related Parties Transactions 233,532 215,139 33,372 32,010

* No transactions were noted with related parties of any Directors of THH, these transactions were conducted with related parties of senior managers in the Department of Health.


Note 25 Provisions

Provisions for liabilities and charges analysis 31 March 2016 31 March 2015

£000 £000

Provisions at start of year 3,271 2,440

Arising during the year 61 925

Utilised during the year- accruals (50) (39)

Utilised during the year- cash (357) (128)

Unwinding of discount 75 73

Released unused (555) -

Provisions at end of year 2,445 3,271

Expected timing of cash flows:

Within one year 125 957

Between one and five years 500 704

After five years 1,820 1,610

Total 2,445 3,271

Provisions are liabilities that are of uncertain timing or amounts which the Trust expects to be settled by a transfer of economic benefits. The provision outstanding at year end relate to staff pensions and has been calculated using information supplied by NHS Business Service Authority Pensions Division. A provision for repayment of national Insurance and tax of £781k was cleared in year by a payment of £226k and reversing the unused balance of £555k.

Clinical Negligence liabilities 31 March 2016 31 March 2015

£000 £000

Amount included in provisions of the NHSLA in respect of clinical negligence liabilities of The Hillingdon Hospitals NHS Foundation Trust 114,089 47,918


7Note 26 Contingent liabilities 31 March 2016 31 March 2015

£000 £000

Contingent liabilities 16 111

The Trust’s contingent liabilities include £90k relating to employee work injuries and £21k relating to public slips or falls.

Note 27 Financial instruments 31 March 2016 31 March 2015

27.1 Financial Assets* £000 £000

Trade and other receivables 17,683 17,757

Cash and cash equivalents (at bank and in hand) 4,092 5,483

Total at end of year 21,775 23,240

31 March 2016 31 March 2015

27.2 Financial Liabilities* £000 £000

Borrowings excluding Finance lease and LIFT liabilities 15,295 16,685


Obligations under LIFT contract 12,390 12,718

Trade and other payables excluding non financial liabilities 22,379 15,228

Provisions Under Contract 2,445 3,271

Total at end of year 57,866 53,542

*Book value is equivalent to fair value

31 March 2016 31 March 2015

27.3 Maturity of Financial Liabilities £000 £000

In one year or less 25,754 19,416

In more than one year but not more than two years 5,437 5,707

In more than two years but not more than five years 5,296 5,608

In more than five years 21,379 22,811

Total 57,866 53,542

Book value Fair value

27.4 Fair values of financial assets at 31st March 2016 £000 £000

Non current trade and other receivables excluding non financial assets 840 840

Book value Fair value

27.5 Fair values of financial liabilities at 31st March 2016 £000 £000

Non current trade and other payables excluding non financial liabilities

Provisions under contract 2,320 2,320

Loans 13,905 13,905

LIFT Contract and Finance Leases 15,887 15,887

Total 32,112 32,112

For current financial instruments (less than one year), fair values are assumed to be equal to book values. Notes 27.3 and 27.4 include only non-current financial assets and financial liabilities.


Note 28 Continuity of Service Risk Rating 31 March 2015 31 March 2015

£000 £000

Metric Criteria Actual Rating Weighting Actual Rating

Capital Service PDC Dividends payable 3,957 3,897

Interest Payments 2,159 2,087

Loans repaid to the Department of Health 1,390 390

Capital element of LIFT 328 181

Capital element of finance lease rental payments 1,652 1,368

Total Capital Service 9,486 7,923

Revenue Available for Debt Service Deficit for the year before exceptionals (1,488) (6,103)

Depreciation on property, plant and equipment 8,717 8,162

Amortisation on intangible assets 654 486

Impairments of property, plant and equipment 0 6,933

Interest Expense 2,084 2,014

Unwinding of Discount Provisions 75 73

PDC Dividends payable 3,957 3,897

Loss on disposal 5 0

Total Revenue Available for Debt Service 14,004 15,462

Capital Service Cover 1.48 2 25% 1.95 3

Cash available for Liquidity Purposes Current Assets 26,279 25,051

Current Liabilities (32,682) (26,623)

Inventories (3,171) (2,778)

Total Cash available for Liquidity Purposes (9,574) (4,350)

Operating Expenses within EBITDA Operating Expenses 234,592 225,839

Depreciation on property, plant and equipment (8,717) (8,162)

Amortisation on intangible assets (654) (486)


731 March 2015 31 March 2015

£000 £000

Metric Criteria Actual Rating Weighting Actual Rating

Impairments of property, plant and equipment 0 (6,933)

Loss on disposal (5) 0

Total Operating Expenses within EBITDA 225,216 210,258

Liquidity (15.30) 1 25% (7.4) 2

Deficit for the year (1,488) (6,103)

Loss on disposal 5 0

Impairments 0 6,933

Normalised Deficit (1,483) 830


Increase in fair value of investment property 494 3,874

Finance income (Interest) 19 17

239,220 225,720

I&E Margin -0.62% 2 25% 0.37% 3

Deficit for the year (1,483) 768

Plan 30

Variance from Plan (1,513)


I&E Margin Variance from Plan -0.63% 3 25% 0.34% 4

Capital Service Cover Rating 2 3

Liquidity Rating 1 2

I&E Margin Rating 2 3

I&E Margin Variance from Plan Rating 3 4

Overall Financial Sustainability Risk Rating 2 3

Note 28 Continuity of Service Risk Rating (continued)


Note 28 Continuity of Service Risk Rating (continued) Financial Sustainability Risk Rating boundaries:

Weighting 4 3 2 1

Capital Service Cover Rating 25% >2.5 <2.5 <1.75 <1.25

Liquidity Rating 25% >0 <0 <-7 <-14

I&E Margin Rating 25% >1% <1% <0 <-1%

I&E Margin Variance from Plan Rating 25% >0% <0% <-1% <-2%

100%

In 2015-16 the Financial Sustainability Risk Rating replaced the Continuity of Service Risk Rating. To facilitate

comparison 2014-15 has been restated in the same format.

Note 29 Third party assetsThe Trust held £11k cash and cash equivalents at 31 March 2016 (£11k at 31 March 2015) which relates to

monies held by the NHS Trust on behalf of patients. This has been excluded from the cash and cash equivalents

figure reported in the accounts.


7Note 30 Losses and Special Payments

31 March 2016 31 March 2015

Losses and Special Payments Numbers Value Numbers Value

£000 £000

Losses

Losses of cash:

Theft/Fraud - - - -

Overpayment of salaries, wages, fees and allowances 4 1 5 -

Other causes 5 - 2 5

Bad debts and claims abandoned

Private patients 3 - 5

overseas visitors 58 131 150 263

Other 16 3 13 1

Stores

Stores Losses 2 50 2 82

Total Losses 88 185 177 351

Special payments

Compensation payments - - 12 76

Personal Injury with advice 7 48 3 13

Other 16 8 24 28

Total Special Payments 23 56 39 117

Total Losses and Special Payments 111 241 216 468

Amounts Recovered 8 9

The amounts reported in this note were incurred as actual costs for the year to date and do not contain any accrued costs. These sums have been reported to and approved by the Audit Committee of the Trust.


Note 31 NHS Hosted charities

Name of Charity: – The Hillingdon Hospitals Foundation Trust General Amenities Fund and Other Related Charities

(The Charity)

Charity Registration Number : 1056493

Corporate Trustee: The Hillingdon Hospitals NHS Foundation Trust

31 March 2016 31 March 2015

From Charity's Statement of Financial Activities £000s £000s

Total Incoming Resources* 610 371

Resources Expended (388) (258)

Resource surplus 222 113

Gains/losses on revaluation and disposal (50) 18

Net Movement in funds 172 131

From Charity’s Balance Sheet 31 March 2016 31 March 2015

£000s £000s

Investments (Non Current Assets) 496 546

Current Assets:

Cash 391 141

Other Current Assets 26 34

Current Liabilities - -

Net assets 913 721

Represented By:-

Restricted Reserves 26 26

Unrestricted Reserves 830 658

Total reserves 856 684

The Charity is controlled by The Hillingdon Hospitals NHS Foundation Trust (The Trust) which acts as Corporate Trustee. Under the accounting standard IFRS 10, the Charity is required to be consolidated within the Trust accounts However the Trust has decided to depart from this standard on the grounds of materiality (Income from the Charity is equivalent to 0.5% of Trust Income); the lack of any meaningful benefit to users of the accounts and the potential excessive costs in terms of management and systems redesign. The detailed accounts of the charity can be found on the Charity Commission website or contacting the Trust’s Finance Department to request a copy.

* The Charitable Funds received a legacy in year of £400k


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