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Committed To Excellence Working Together Facing The Future

Annual Report and

Accounts

Hospital Trust of the Year in the South: Dr Foster Hospital Guide 2013

2013-2014

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Annual Report and AccountsV2.pdf 1 03/06/2014 15:26

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Presented to Parliament pursuant to schedule 7, paragraph 25(4) (a) of the National Health Service Act 2006

Frimley Park Hospital NHS Foundation Trust

Annual Report and Accounts 2013-2014

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Overview

Frimley Park Hospital NHS Foundation Trust is a district general hospital located in Surrey, close to the Hampshire and Berkshire borders. The Trust provides a full range of district general hospital services to the population of North East Hampshire and West Surrey, and parts of East Berkshire with a wider catchment for specialist services. The catchment population has grown significantly from 170,000 in 1974 when the hospital was built to between 400,000 and 500,000 today, and this figure is expected to continue to grow.

With 4,200 employees and about 750 beds, the Trust provides a full range of consultant delivered services specialising in acute services of:

Primary Percutaneous Coronary Intervention (heart attack treatment)

Vascular

Cystic fibrosis

Spinal

Stroke

Since 1996 the Trust has hosted a Ministry of Defence Hospital Unit, with military staff fully integrated with NHS colleagues across the hospital.

Due to its consistently strong performance over several years, Frimley Park Hospital became a foundation trust on 1 April 2005, the first non-specialist foundation trust hospital in the South East region. As a foundation trust, it is accountable to its local community and aims to have a membership representative of its catchment area, with members providing feedback to the Trust on the services that it provides. The Trust has consistently achieved strong performance and finance ratings from the Regulator of Foundation Trusts, Monitor. In December 2013, Frimley Park Hospital was named Hospital Trust of the Year in the Dr Foster Hospital Guide 2013 for the South of England. The award followed four consecutive years of the Trust being ranked among the top 10 safest hospital trusts in the country by Dr Foster.

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Contents Annual Report 2013 - 2014

Strategic report Overview of the Trust 4

Contents 7

Statement from the Chairman 8

Business review and the year ahead from the Chief Executive 12

Financial and activity and risk review 23

Our patients 31

Our people 44

Working in partnership 50

Sustainability 56

Governance

Directors’ report 60

Board of Directors 60

Corporate governance 68

Directors’ responsibilities statement and Going Concern 83

Council of governors and membership 84

Remuneration report 98

Statement of the Accounting Officer

108

Annual Governance Statement

109

Quality Report 2013-2014

125 (1)

Accounts 2013-2014

199 (1)

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Strategic report – Statement from the Chairman

Mike Aaronson, Chairman

I am pleased to present Frimley Park Hospital’s results for the year ended 31 March 2014.

It has been another year of accolades. For example, after winning a similar title the previous year, we were named Trust of the Year for the South of England in the Dr Foster Hospital Guide, published in late 2013. In February our Board was named NHS Board of the Year for England by the NHS Leadership Academy. The Trust also excelled in its Care Quality Commission report after we were one of the first in the country to be inspected under a new comprehensive regime.

These achievements were realised against a backdrop of continued change in the NHS. In autumn 2013 there were fears that seasonal sickness and squeezed budgets could lead to meltdown in our healthcare system. But the NHS came out of the winter in much better shape than many had predicted. It is true that the winter was relatively mild with less flu than usual. However we should not underestimate the efforts of NHS staff. Ours at Frimley excelled themselves yet again. We had many days when the hospital was under extreme pressure, yet staff continued to focus on delivering excellent care. The 95% waiting target in the emergency department and our other key targets were met against the odds, despite more patients than ever being treated on the wards and in clinics.

Looking ahead it is clear that future winters, or indeed summers, are not going to get easier. With an estimated 2,000 patients admitted to the hospital with dementia in the year, we know that budgets will not keep pace with demand from an ageing population; even high performing and solvent trusts such as Frimley Park Hospital will falter without radical change. As the new NHS chief executive has said, we need a revolution in the way patient care is delivered. In short, even successful trusts like ours cannot sit back.

We are already doing a lot to meet the challenges, such as reducing length of stay by supporting discharged patients at home and increasing the number of senior doctors in hospital around the clock and at the weekend. But delivering the bigger ideas that will break down barriers between different parts of the healthcare system requires more scale.

This is the driving force behind our potential acquisition of Heatherwood and Wexham Park Hospitals NHS Foundation Trust (HWPH). We and the HWPH Board have been exploring this possibility throughout the year and following an outline business case both boards decided to give their support in principle provided a number of conditions were met. The acquisition would provide a larger catchment population to enable the enlarged Trust to

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sustain existing specialist services. It would also provide an option to develop the Heatherwood Hospital site as a centre for planned surgery to serve patients from both trusts’ existing catchments, taking some pressure away from both the Frimley and Wexham Park sites.

At the time of writing this report, we have produced a full business case which is being reviewed by the Board and will be scrutinised by the regulator Monitor, and the Department of Health. We are also pleased that the potential acquisition has been cleared by the Competition and Markets Authority (previously the Office of Fair Trading) after they found it would result in no adverse impact on competition. A decision on the acquisition requires careful consideration and approval by the Board and the Council of Governors, which will be sought in July 2014. Whether we ultimately decide to proceed or not with the acquisition, continuing to deliver high quality and sustainable improvements in patient care calls for some bold decisions. In future years funding is unlikely to keep pace with demand and meeting quality standards outlined by the Royal Colleges, including seven day working, will need a step change in how we deliver services. It is better that we take those decisions now, while we are in a position of strength.

We have therefore devoted much thought to the potential acquisition, but we have not lost sight of our usual business, and it has been a remarkable year in many other ways.

A highlight was welcoming back HRH The Countess of Wessex to open our new neonatal unit. It was the first time the Countess had been to Frimley Park since her second child James, Viscount Severn, was born here in 2007. This new unit was made possible by the generous reaction of the public and staff to our “Saving Tiny Lives” fundraising appeal. We continue to be grateful for the support we enjoy from our community, as evidenced not only by our fundraising successes but also by our vibrant membership, the packed turnouts at our local health events, and an enthusiastic online community. This year our new Breast Care appeal has got off to a flying start.

I would like to take this opportunity to thank the Board for its leadership and support throughout the year. In particular, I would like to congratulate the Chief Executive, Andrew Morris, on being voted one of the ‘Top Ten NHS Leaders’ by the Health Service Journal. There have been a number of Board changes this year. On 1 April 2013 we welcomed David Clayton-Smith, the former chairman of both Surrey and Sussex primary care trusts, as a non-executive director, and in July we welcomed Helen Coe MBE to the newly created interim post of Director of Operations. Helen had previously been a very successful Associate Director for Medicine and Urgent Care services.

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In December 2013, chest consultant Dr Tim Ho joined the Board as our new Medical Director, having worked at Frimley Park Hospital for nine years. Tim replaced Mr Edward Palfrey OBE on the Board after Edward decided to step down in December 2013 following 13 tireless years in post. I would like to pay special tribute to Edward for his contribution to the Board. He was a member in 2005 when it took the historic decision to become one of the first foundation trust hospitals in the country and has been part of a team that has overseen the strategy to invest tens of millions in medical services and infrastructure, including a regional heart attack centre, a landing pad for air ambulances, and one of the most modern emergency departments in the country. I am pleased to say that Edward remains at the Trust as a senior consultant urologist and has retained his role as Responsible Officer for consultants’ revalidation. We are also using some of his long experience to support the clinical modelling work associated with the potential integration of services with HWPH.

I am very proud of the strong and effective working relationship that exists between our Board of Directors and the Council of Governors. A committed and knowledgeable Council of Governors has been one of the cornerstones of our success and will have a key role to play in the future. I would like to thank all its members for their support and challenge to the Board in shaping the organisation’s future strategy. I was very pleased that elections for public governors in March saw the highest number of candidates stepping forward since our first in 2005. It meant we said goodbye to some long-serving governors, whom I would like to thank for their excellent service, and welcomed nine new public governors and two staff governors who I am sure will prove to be worthy replacements.

In short, we have had an exceptional year at Frimley, but we are very conscious that the year ahead will pose enormous challenges for all of us. I look forward to being able to report on progress a year from now.

Sir Mike Aaronson Chairman 22 May 2014

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NHS Board of the Year for England, NHS Leadership Academy

Back row from left to right: Janet King, Martin Sykes, Rob Pike, Stephen Crouch, Andrew Morris, Helen Coe, David Clayton-Smith, Tim Ho Front row from left to right: Nicola Ranger, Mike Aaronson, Tina Oakley, Mark Escolme, Andrew Prince

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Strategic report – Business review and the year ahead

Andrew Morris, Chief Executive

I am pleased to present this review of our work for the year ended 31 March 2014.

Colleagues often tell me they work ‘for Frimley Park’, not ‘at Frimley Park’. This, for me, epitomises the strong set of common values that has helped us to become one of the best performing NHS acute trusts in the country. It demonstrates a level of commitment and engagement that results in great patient care.

Last year we embarked on a project to help us articulate our values better, so that we could embed them into the organisation and ensure that they underpin everything we do now and in the future. At a number of forums and workshops staff were asked what working for Frimley Park meant for them. The result was a set of self-generated values – ‘Committed to Excellence, Working Together, and Facing the Future’ – that all of us can sign up to.

We wanted the values to mean something to staff, and have integrated them in our processes, from recruitment to appraisal, and encouraged staff to challenge behaviour that does not live up to them. Just a few months after they were introduced we added a set of questions of our own to the national staff survey to find out if they were working. Results showed that more than nine out of ten staff understood the values and that the vast majority related to them, felt they could explain what they meant and supported what the Trust was trying to do through its values. They also showed 82% of staff agreeing that they were proud to work for Frimley Park Hospital; a result any organisation would be delighted with.

Inspectors from the Care Quality Commission (CQC) were also struck by how widely known our new values were and how well staff could relate them directly to their work. Throughout the year there were countless examples of staff living the values, both collectively and individually. I hope that this comes across on our Annual Report for 2013-2014.

With commissioners planning to locate more services in the community we had anticipated a levelling off of demand for our services. However patient activity increased in 2013-2014. In particular emergency admissions were up by 1,500 on the previous year to 35,000. The Trust saw 109,000 attendances in the Emergency Department (up by 5,000 on the previous year) and 113,000 new outpatient appointments (up by 5,000). By treating 47,000 surgical patients as day cases, 5,000 more than last year, we were also

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able to increase efficiency by reducing bed days and in most cases shortening recovery times.

During the year we also approved an investment of £3.5m to create an additional high dependency unit to increase our capacity to treat critically ill patients. By putting both surgical and medical high dependency beds in the same location close to the intensive care unit, we are also rationalising the service in a way that will make a big difference to the very sickest patients. Dr Foster named Frimley as the best Trust in the South of England for mortality and safety, which demonstrates the staff’s commitment to maintaining good clinical outcomes.

The Trust finished the financial year £6.5m in surplus on a turnover of £291.9m, which was slightly ahead of plan reflecting another year of growth in the number of patients treated. This still represents a very small margin on our turnover of £291.9m. Although we achieved our savings target of £9m, we were not able to reduce bed capacity as planned, particularly over the winter. Foundation trust regulator Monitor, who scrutinise our finances throughout the year, gave us a risk rating of 4 for finance and continuity of service, one off the maximum rating, for each quarter of 2013-2014. In addition Monitor gave the Trust a ‘green’ rating for each quarter, indicating that there were no significant issues with our performance as measured by indicators such as MRSA and clostridium difficile infection rates, and waiting times for ED, outpatient and cancer services.

The CQC, the regulator of health services in England, selected Frimley Park Hospital as one of 18 trusts to pilot its new style of inspection. The CQC wanted trusts with a range of risk profiles for its pilot and ours was among the group of ‘low risk’ trusts selected. It meant that in November 2013 we were visited by a large team of inspectors who spent three days examining every aspect of our patient care at close quarters before compiling a detailed report into their findings.

The result was extremely positive. In my experience it is very rare for inspectors to comment directly on overall staff attitude, so to read that they found ours to be ‘overwhelmingly happy’ was very gratifying and again demonstrates how much positive impact this has on patient care. In my book happy staff equals great care.

The report also found excellent leadership at every level and reserved special praise for our emergency department and end of life care. Inspectors also took note of a number of touching interactions between patients and staff, reflecting a good caring attitude. Of the 42 or so inspections carried out by the CQC so far under its new regime, the report into our Trust remains among the very best.

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FRIMLEY PARK HOSPITAL OUR VISION

To be recognised, locally and nationally, as the leader in quality healthcare – delivering safe,

clinically effective services focused entirely on the needs of our patients and their relatives and carers.

OUR VALUES

Committed to Excellence Working Together Facing the Future

STRATEGY 2013-2016

STRATEGY

We will continue to deliver clinical excellence for our existing patients while seeking to expand our catchment and to reach a wider population. This will also provide greater scale and resilience for

our services and will allow us to work with our commissioners and other providers to deliver quality care in local settings while driving for greater efficiency and improved service delivery.

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Hyperacute services are pivotal to the success of our strategy. Ensuring we achieve the nationally recognised standards of care for these services means patients can be confident that the care they receive will be the best it can be.

To be a Centre of Excellence recognised for specialist services:

Achieve the standards needed for specialist service status from the National Commissioning Board for: Vascular, pPCI, Trauma, Cystic fibrosis, Spinal, Stroke, Foetal medicine

Build on Frimley’s unique selling point of having more consultant-delivered emergency services out of hours than any other local hospital.

OBJECTIVES TO ACHIEVE THE STRATEGY

Hyperacute

OUR VALUES By being committed to excellence and by

working together, we will face the future with a focus on efficiency and improvement to ensure our continued success as a leading healthcare

Quality and Efficiency

Monitor green for quality and

finance

Mortality rates in best quartile

Excellent

customer care

Compliance with CQC

Productive workforce

Non – NHS Income

Bespoke

service for MoD

Develop private

patient care

Increase R&D and

innovation

Local Health Care

Local

chemotherapy

Quality care in community

settings

Supporting long Term

conditions and elderly people

at home

In Hospital Care

Advanced diagnostics

Increased

theatre capacity

Saturday running

Excellent obstetrics and

Paediatrics

Hyperacute

Recognition as a centre of

excellence for:

Vascular pPCI

Cystic fibrosis Spinal Stroke

Foetal med

Consultant Delivered

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The only significant issue that inspectors raised was around continued awareness in managing patients with dementia and memory impairment. We currently admit about 2,000 patients every year with dementia as a main diagnosis and that number is increasing. So we are putting a dedicated ward in place for patients with dementia and working with the Alzheimer’s Society to improve facilities. Once again the latest annual NHS staff survey showed we have among the best and most engaged workforce of any NHS hospital in the country. The Trust has scored consistently well in this national survey since it was started in 2003. The latest results were among our best ever, scoring us in the best 20% of trusts in 17 of the 28 areas tested, above average in six more and below average in just two. In addition, this year we achieved a bronze status in our Investors in People (IiP) award, something that only 5% of IiP organisations achieve, and were named as ‘one to watch’ in the Sunday Times Best Companies scheme for 2013. We remain ahead of the curve in providing more consultants and senior doctors out of hours in acute specialities. For example if you come into ED between 8am and midnight (and often later) there will be a consultant on duty in the department either delivering care or supervising others. We have also provided more consultants in the front line out of hours in many other specialities such as on the labour ward, in cardiology (with our 24-hour heart attack centre), respiratory medicine, stroke care and vascular surgery. This not only results in better quality care for patients, it also offers junior staff an extra level of support and confidence by having senior colleagues on hand. This is perhaps one reason why our junior doctors voted us the best trust for training in the Kent Surrey and Sussex Deanery area. In addition we have been looking at our nursing ratios on wards and have already invested an extra £2m to provide a 1:8 ratio for nurses to patients during the day and 1:10 at night. I believe this investment in front line staff, especially at consultant level, is a major factor behind our consistently lower than expected mortality rates. In fact, in 2013 we were named as the Best Trust in the South of England in the Dr Foster Hospital Guide based on patient mortality and safety. This follows the previous year’s accolade of being named runner-up Trust of the Year in England in the same guide in 2012. Quality standards continued to improve overall. Some of the key indicators are shown in the table below, with significant reductions in pressure ulcers and falls and improve-ments in patient assessments for VTE (venous thromboembolism) and harm-free care. In fact harm rates have been reduced by 53% over the period 2009-2012. While the gradual decline in MRSA and Clostridium difficile infections levelled off this year from a low base, causing us to miss our internal targets for absolute numbers, they remain among the very lowest rates of hospital acquired infection in the region. The fact that we had another year free from norovirus, which can be debilitating for patients and extremely

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disruptive in a hospital, is a reflection of the good work of our infection control team and the discipline of our staff in following good practice. Quality standards

Indicator 2010-2011 2011-2012 2012-2013 2013-2014 Trend 1

MRSA 3 2 1 4

C. difficile 25 15 16 15

Pressure ulcers grade 2 243 247 144 90



% of falls resulting in significant injury

0.1% 0.08% 0.03% 0.02%

VTE % risk assessment 83% 91% 93% 97%

NHS safety thermometer (% harm free care) 2

NA NA 93% 95%

Source: Trust performance data and NHS Safety Thermometer March 2014. 1 Trend over time relates to the performance against baseline data – the first full year of data collection for each indicator shown in brackets. Thumbs horizontal = performance maintained, thumbs up = performance improved, thumbs down = performance worsened. 2 The safety thermometer is national tool used to measure harm from falls, pressure ulcers, VTE and catheter associated urine tract infections

In women’s and children’s services, we invested £1m to upgrade the Special Care Baby Unit. By locating it in a bigger ward with better equipment – funded by generous community support for our Saving Tiny Lives Appeal – it now has neonatal unit status capable of treating babies who are born more prematurely. Our labour suite is in the process of being upgraded so that all rooms have en-suite facilities and a better environment and later this year we will be opening a newly-created midwife-led unit where mothers expecting a lower risk birth can choose a more homely environment. These improvements are part of the Trust’s Strategy 6000, which is planning for an anticipated increase in births to 6,000 per year in 2015. In addition we have invested in additional paediatric consultant cover between 8am and 10pm. Along with improving outcomes and quality we are also focused on patient experience. We remain eager to listen to feedback so that we can understand our patients’ needs and change practice for the better. Most of the feedback we receive through a number of channels and systems is very positive. For example our Friends and Family Test results are generally very good both in terms of the quality of feedback and the number of patients taking part. Results from the national cancer survey were the best locally, but

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among the feedback was concern from some patients at not being able to access a dedicated cancer nurse at weekends. As a result we have now extended nursing cover at weekends.

Looking ahead longer term the Trust has recognised that it requires a much larger catchment population if it is to maintain the excellent specialist acute services, such as vascular, stroke and heart attack, that help us to recruit and retain some of the best staff in the country. A larger catchment would also put us in a strong position to host a ‘super emergency department’ as outlined in NHS medical director Professor Sir Bruce Keogh’s vision of a national acute care network, and to continue to increase efficiency without reducing front line services. As the Chairman has outlined in his report, for much of 2013-2014 we have been exploring the possibility of acquiring a neighbouring trust of similar size to create a single trust with a catchment population of 800,000-plus. Heatherwood and Wexham Park Hospitals NHS Foundation Trust serves patients in East Berkshire and South Buckinghamshire and has recently been placed in special measures after several years of poor performance. Although this has taken up a lot of time at senior level, I hope the rest of my report has demonstrated that we have not lost sight of business as usual during the year. Where possible we have used external resources to support this process and help us engage with our healthcare partners appropriately. After an outline business case for the acquisition was developed in August 2013 both boards announced in January 2014 that we would be creating a full business case, including a clinical vision for the new entity. That vision includes retaining full services on main hospital sites at Frimley and Wexham Park, so we would not be asking patients to travel extra distances for their care. It also envisages a new elective care centre at Heatherwood in Ascot and the potential to develop more hyperacute services that are currently sourced from outside the area. We do not underestimate the task if we decide to go ahead with the acquisition later this year. We will only do so if we truly believe we can create a new single trust with, over time, an excellent standard of care for all. Doing so will require the appropriate level of support centrally and locally. But we know we cannot stand still if we are to retain the excellent portfolio of services and the staff that run them.

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Our values, Committed to Excellence, Working Together and Facing the Future, are helping staff to focus on what matters most in providing excellent care to patients and continually improving. After they were developed in 2013, the key messages were communicated to staff through a number of engagement events and mechanisms, such as a leaflet given to all staff and posters produced for all Trust sites.

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Achievement of objectives

Finance:

The Trust is on track for a rating from Monitor of 4 for quarter four (5 being the best possible).

Surplus of £6.5m on a turnover of £291.9m.

The year-end cash position was £49m. The cash holding represents just over 60 days of operating expenses, comfortably ahead of the desired minimum of 30 days.

Cost improvements / Innovation and Change plan: the Trust delivered savings of £8m in 2013-2014, slightly below plan but this was offset by higher activity levels.

The initiative to reduce bed capacity needed to be reversed as a consequence of the 4% increase in medical workload and a 9% increase in surgical emergencies.

Governance:

The rating from Monitor for Q4 is expected to be green. Performance on C.diff was 15 cases against a target of eight. The Trust therefore exceeded Monitor’s de minimis level of 12. Although the target was exceeded, overall C.diff rates remained in the top (best) quartile. The total for 2012-2013 was 16 so there was a slight improvement against the previous year. There were no norovirus outbreaks during the year in contrast to a number of local trusts that were required to close wards due to outbreaks of the virus.

Performance on MRSA was four cases – Monitor allows a de minimis of six. In 2012-2013 the total was two.

There were no outstanding issues from the CQC inspection.

In respect of nationally measured mortality rates, the latest 12 month peer comparison showed that Frimley mortality rates for period January to December 2013 were better than four of the five peer trusts.

Other key achievements:

The ED four-hour waiting target was delivered for the year.

Work commenced on the development of the full business case for the acquisition of Heatherwood and Wexham Park Hospitals NHS Foundation Trust. The Competition and Markets Authority gave clearance on competition grounds following a review started in March 2014.

Plans to establish ward F14 as the dementia ward were developed with an upgrade in two phases.

The private patient unit upgrade was started.

In the national staff survey FPH had the best performance of any local trust.

The Board was declared ‘Governing Body of the Year’ by the NHS Leadership Academy.

A review of the nursing establishment was undertaken and an additional £2m invested to move to a 1:8 nurse to patients ratio during the day and 1:10 at night.

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The year ahead

We are now looking forward to an eventful year ahead when the Board and the Council of Governors will decide whether to acquire Heatherwood and Wexham Park Hospitals NHS Foundation Trust.

We have set ourselves a range of challenging targets and objectives:

To achieve the compliance regime

To continue with the acquisition of HWP

To enhance hyperacute services further

To improve in-hospital care

To deliver care locally

To maximise non-NHS income

To improve quality and efficiency

With regards to the improvement of in hospital care, we intend to roll out the leadership development programme for all heads of nursing and matrons. We plan to develop a staffing tool to ensure nursing levels comply with our desired minimum ratios of 1:8 patients on day shifts and 1:10 for nights. We plan to make all wards and departments dementia friendly and create a dementia specialist ward with the appropriate state of the art design features. The Board and the Council of Governors will embark on a dementia training course in support of the Trust’s dementia strategy. The Trust continues to develop a consultant-led service by extending the seven day consultant-led service across all disciplines.

We will continue the investment in our services with a further £13m of capital projects including the upgrade of the labour ward to include a midwife led unit, an upgrade to the communal area in the Parkside private care facility, a new ward serving an acute dependency unit for medicine and surgery, and extra elderly care beds.

With regard to the improvement of the delivery of care locally, the Trust will continue to expand its outreach rehabilitation team to provide integrated care for patients, develop a new elderly care model with the aim of providing a service integrated between the community and the hospital, launch a mobile unit to treat age related macular degeneration, and develop further chemotherapy services for patients locally.

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The Trust plans to save a further £10m, continuing our aim of meeting tough financial challenges. Should the Board decide to proceed with the acquisition of HWPH, its objectives for the year will need to be reviewed and tailored for an enlarged organisation.

Finally, I would like to take the opportunity to thank all staff who have contributed to another successful year in which we achieved almost all our major objectives and targets. Face with unprecedented demand, they kept services running well and I continue to be proud every day to work alongside such dedicated and motivated colleagues.

Andrew Morris Chief Executive 22 May 2014

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Strategic report – Financial, activity and risk review

Martin Sykes, Director of Finance

Principal activity

Frimley Park Hospital NHS Foundation Trust (the Trust) is a district general hospital located in Surrey, close to the Hampshire and east Berkshire borders. With 4,200 employees and about 750 beds, the Trust provides a full range of consultant delivered services across Surrey, Hampshire and parts of East Berkshire specialising in acute services of:

Primary Percutaneous Coronary Intervention (pPCI)

Vascular

Cystic fibrosis

Spinal

Stroke

Since 1996 the Trust has hosted a Ministry of Defence Hospital Unit, with military staff fully integrated with NHS colleagues across the hospital. The Trust also owns and manages Parkside, a private patient facility. All surplus income from this unit is reinvested into the NHS facilities at the Trust.

Due to its consistently strong performance over several years, Frimley Park Hospital became a foundation trust on 1 April 2005, the first non-specialist foundation trust hospital in the South East region. As a foundation trust, it is accountable to its local community and aims to have a membership representative of its catchment area, with members providing feedback to the Trust on the services that it provides. The Trust has consistently achieved strong performance and finance ratings from the Foundation Trust Regulator, Monitor. In December 2013, Frimley Park Hospital was named Hospital Trust of the Year in the Dr Foster Hospital Guide 2013 for the South of England. The award followed four consecutive years of Frimley Park Hospital being ranked among the top 10 safest hospital trusts in the country by Dr Foster.

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Activity review

During 2013-2014, the Trust continued to provide a range of major general hospital services to its catchment, including:

A full emergency service

Elective and emergency services in surgery and medicine

Women’s and children’s services

Therapeutic, diagnostic and pharmaceutical services

In 2013-2014 the Trust saw a 5% increase in referrals from GPs compared to the previous year. The biggest increase in GP referrals over the past five years has come from the Berkshire area.

Military referrals fell by 11% in 2013-2014 due to the change in commissioning arrangements in 2012-2013, which led to a shift of elective work away from Ministry of Defence Hospital Units (MDHUs), such as the one based at Frimley Park Hospital, in favour of more local providers.

In terms of activity, the Trust’s elective workload in 2013-2014 was broadly similar to 2012-2013, although the proportion of patients being treated as day cases rather than inpatient cases continued to rise. In 2013-2014 approximately 86% of elective activity was undertaken on a day case basis (2012-2013: 84%).

As a result of the increase in GP referrals exceeding the increase in capacity, waiting lists for both outpatients and inpatients have grown during 2013-2014. We are working to reduce the waiting lists during 2014-2015.

There was a 4% fall in maternity activity during 2013-2014 with a total of 5,318 births (2012-2013: 5,564 births), reflecting an overall decrease in national birth rates coupled with a slight fall in market share.

Emergency admissions continue to rise. There was a further 5.2% increase in emergency attendances during 2013-2014 (2012-2013: 6.5%), making a 13.7% increase in total over the past five years, which continues to create operational challenges for the hospital. We treated 3.3% more emergency admissions.

Of the emergency attendances, some 7,000 were patients with dementia, reflecting a growing trend in the treatment of acute conditions for an ageing population.

The following tables show the five year history of aggregate activity including private patient work.

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Outpatients

Attendances Attendances Attendances Attendances Attendances

2013-2014 2012-2013 2011-2012 2010-2011 2009-2010

Frimley Park Hospital

330,646 309,239 306,545 298,767 268,820

Farnham Hospital

24,066 23,431 24,378 24,480 24,093

Fleet Hospital

17,040 15,886 15,213 13,230 11,907

Aldershot Centre for Health

27,211 28,682 30,974 28,027 31,672

398,963 377,238 377,110 364,504 336,492

Elective activity

2013-2014 2012-2013 2011-2012 2010-2011 2009-2010

(spells)1 (spells)1 (spells)1 (spells)1 (spells)1

Day cases 47,765 43,728 43,062 39,701 37,707

Inpatients 7,740 8,351 8,852 9,051 8,861

Births 5,318 5,564 5,399 5,230 5,025

60,823 57,643 57,313 53,982 51,593 1 A spell is a discrete period of care in hospital. The calculation of all these figures has been reviewed to reflect recent national changes to counting and coding. For example regular attenders are now included as day cases and ward attenders and pre-ops are included in outpatient figures. This accounts for slight variations in these figures compared with previous annual reports.

Non-elective activity

2013-2014 2012-2013 2011-2012 2010-2011 2009-2010

ED attendances 109,649 104,240 103,206 101,480 96,411

Emergency admissions

34,927 33,785 31,719 29,598 27,637

Patients on waiting lists at 31 March

March 2014

March 2013

March 2012

March 2011

March 2010

Outpatients 8,810 7,284 5,972 6,606 6,867

Inpatients 4,416 4,393 3,325 3,972 3,375

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Monitor regulatory ratings The Trust is regulated by Monitor, to whom it submits its annual plan. On the basis of the information contained in the annual plan and in-year submissions, Monitor will assess and assign a risk rating for the Trust.

The Trust’s financial performance has been in line with or slightly ahead of its plan throughout the year, resulting in a Monitor risk rating of 4 in each quarter.

Foundation Trusts are allocated a ‘governance rating’, which is awarded by Monitor after using performance against national targets as a proxy for good Board governance. Target performance is summarised in the quality report section of this document. The Trust was awarded a ‘green’ governance rating in each quarter of 2013-2014.

Frimley Park Hospital NHS Foundation Trust regulatory rating 2013-2014 (Monitor)

The Trust’s ratings throughout the previous year were as follows:

Frimley Park Hospital NHS Foundation Trust regulatory rating 2012-2013 (Monitor)

1 Annual plan review and in-year reporting and monitoring Monitor uses the information provided in the annual plan primarily to assess the risk that an NHS foundation trust may breach its licence in relation to finance and governance and assigns risk ratings. Every quarter, NHS foundation trust boards are required to submit details of performance in the most recent quarter and year-to-date against their annual plan, and self-certify that all healthcare targets and indicators have been met. Each trust is assigned an overall financial and governance risk rating for the quarter based on the declarations they make to Monitor.

2 Financial risk rating (FRR) Continuity of Service (COS) rating Risk ratings are assigned using a scorecard which compares key financial metrics consistently across all foundation trusts. The risk rating reflects the likelihood of a financial breach of an NHS foundation trust’s provider licence. The FRR rating applied for quarters 1 and 2. A COS rating was introduced from quarter 3. Under the FRR, a rating of five reflects the lowest level of risk and a rating of one the highest. The highest rating under the COS rating is four.

3 Governance risk rating Monitor rates governance risk using a graduated system of green, amber-green, amber-red and red, where green indicates low risk and red indicates high risk.

4 Monitor to confirm rating

There were no formal interventions by the regulator during the year 2013-2014.

Annual Plan 2013-20141

First quarter (Q1)

Q2 Q3 Q4

Financial risk/ Continuity of service risk rating 2

4 4 4 4 4

Governance risk rating3 Green Green Green Green Green4

Annual Plan 2012-20131

First quarter (Q1)

Q2 Q3 Q4

Financial risk rating 2 4 4 4 4 4

Governance risk rating3 Green Green Green Green Amber/Green

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Financial review

The Trust achieved its financial plan for 2013-2014, delivering a surplus of income over expenditure for the year of £6.5m (2012-2013: £8.1m). Income and expenditure both increased substantially on the previous year, reflecting a continuing rise in patient activity, not all of which had been planned either by the Trust or by local commissioners.

2013-2014(£m)

2012-2013 (£m)

Increase (%)

Operating income 291.9 279.6 4.4

Operating expenses 280.9 267.4 5.0

The Trust’s income from the provision of goods and services for the purposes of the National Health Service is greater than its income from the provision of goods and services for any other purposes. There has not been any significant impact from other income on the provision of goods and services for the purposes of the health service in England.

The Trust invested £10.2m in infrastructure and equipment during the year (2012-2013: £11.6m), broadly comparable with the level of in-year depreciation of £9.1m. Significant in-year programmes included:

Upgrading one of the Trust’s vascular theatres

Opening the new expanded neonatal special care unit and refurbishing the labour ward

Adding a second interventional radiology suite

Adding a fluoroscopy unit

A £4m investment in a new level one/two high dependency unit and a new general medical ward. This will be completed in May 2014

Completion of phase one of a two phase £0.5m upgrade to the public and communal areas in the Parkside private suite, with the second phase to be completed in the summer of 2014.

Together with the usual infrastructure upgrades and equipment replacement programmes, we have continued to invest in top end technology (vascular and interventional radiology) while maintaining our general infrastructure.

The Trust’s cash holding increased by £8m on the previous year to £49m at 31 March 2014 (31 March 2013: £41m). The Trust also had access to a committed working capital facility of £12.5m that was not used during the year.

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Towards the end of 2013-2014, the Trust requested the District Valuation Office to conduct a desktop revaluation of its estate. As on previous occasions, the valuation used the ‘modern equivalent asset’ method, based on the cost of replacing losses with similar up-to-date counterparts. The revaluation resulted in a £9.3m increase in the fair value of the Trust’s infrastructure. Details of the revaluation and market value of the fixed assets are shown in note 8.1 to the Trust’s accounts.

The Trust follows the ‘Better Payments Practice Code’ and aims to pay all relevant creditors within 30 days. Performance against this standard is detailed in note 10.1 of the Trust’s accounts. The Trust also aims to pay smaller creditors as quickly as internal processes allow.

The Trust operated well within its prudential borrowing limit (set by Monitor) as detailed in the appended annual accounts. The Trust has complied with the cost allocation and charging requirements set out in HM Treasury and Office of the Public Sector information guidance.

Risks

The Executive team continually reviews the corporate risk register and updates it at least monthly on a formal basis, at the Corporate Governance Group meeting. The Corporate Governance Group considers the most significant corporate risks, ranked ‘high’ or ‘extremely high’, as well as those where the risk has been reduced since its last review. The Corporate Governance Group reports its findings to the Board. The Risk Register is published on the Trust’s website in the Board papers. The Board recognises that the Trust’s strategic objectives can only be achieved if any potential risks are monitored and managed effectively. The register enables the Board to identify and understand the most significant risks, both internal and external, that are critical to the success of the organisation.

Principal risks and uncertainties

At the date of this report, the Board has identified the following key financial and non-financial risks in its Risk Register:

Acquisition of Heatherwood and Wexham Park Hospital NHS Foundation Trust and the potential of a failure to achieve the work required within timeframes while maintaining performance at Frimley Park Hospital

Risk of a failure to deliver the informatics strategy as a key part of the quality and efficiency objective

Risk to financial stability through the transformation/savings plan not being achieved and costs therefore exceeding plan

Risk of poor patient experience through the patient transport service not fully meeting requirements.

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Financial risks

The Trust ended 2013-2014 in a strong financial position, with a surplus of £6.5m, although this declined slightly compared to the previous year (2012-2013: £8.1m). Like all NHS organisations, the Trust will be required to deliver further considerable efficiency savings over the coming years (4% in 2014-2015, 4.5% in 2015-2016). The Acting Director of Operations has worked with Trust managers and clinicians to develop a plan that has delivered £8m of savings for 2013-2014 and is planned to deliver £9m of cash releasing savings in 2014-2015.

Looking ahead, the NHS aspires to move activity out of hospitals and into community settings (GP surgeries and patients’ homes). This will almost certainly reduce future activity growth and may even reduce activity and therefore income levels at the Trust. In 2015-2016, the ‘Better Care Fund’ will move resource from the NHS into social care. The Trust is working closely with commissioners to identify areas where this shift of resource might help to reduce demand on the acute sector.

In addition to activity changes, income levels are at risk from changes to the tariff (the rate at which hospital trusts are paid for treating patients) and other financial penalties and incentives that may be introduced. The uncertainties within the first year of the two year plan are largely related to activity, given that the tariffs have already been published by Monitor. Moreover Monitor has signalled that there may be significant change in NHS pricing and reimbursement mechanisms in 2015-2016, although clearly the Trust will not be able to gauge the potential impact until more details are available.

The Trust’s financial plans include an expected 1.9% rise in pay costs, a 2.5% rise for non-pay items and services and a 7.2% increase for drugs due to price inflation and growing demand for new treatments. The Trust has also incorporated additional sums for known cost pressures, such as staffing more beds and increasing consultant numbers. These anticipated cost rises have been partially offset by the Trust’s cost improvement and efficiency programme, comprising schemes totalling £9m. Taken together with other planned activity and income changes, the Trust anticipates being able to continue to generate a surplus in 2014-2015, albeit marginally lower than in 2013-2014.

Non-financial risks

Key non-financial risks faced by the Trust include the continued drive to move activity outside of hospitals and to bring further competition for services. It is anticipated that services will increasingly be open to competition from new providers with, for example, the national ‘Any Qualified Provider’ arrangements being used to encourage new providers into the marketplace. The Trust continues to work closely with local GP leaders with an aspiration to ensure that changes to patient pathways are devised jointly with hospital consultants, and that any suggested changes are clearly in the best interest of patients and support clinical quality.

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Other key risks include the continuing impact of increasing levels of unplanned patient activity (emergency admissions), where again the Trust is working with stakeholders such as GPs to ensure that out-of-hospital services are fit for purpose. The Trust carries reputational risk around the delivery of key national targets, particularly the four-hour emergency department waiting standard and challenging infection control targets.

Personal data-related incidents

The Trust delivers annual information governance training for all staff, raising awareness of the importance of protecting patient information. Training also encourages staff to report personal data related incidents. All reported incidents are investigated by the Trust’s information governance (IG) team. Where applicable, Trust policies and procedures are revised to prevent incidents recurring and lessons learnt are incorporated into the Trust’s IG training.

The Trust has a network of IG champions and information asset owners (IAOs) who work together to implement the Trust’s Annual Information Governance Work Programme to ensure the security and management of the Trust's information assets. The Trust’s score at the end of March 2014 in the Information Governance Toolkit was 75%. A comprehensive work programme has been developed to increase the Trust’s Information Governance Toolkit score in 2014-2015.

In 2013-2014 the Trust reported no serious untoward incidents involving personal data.

The Trust does not charge a fee for providing information requested under the Freedom of Information policy if the cost of compiling the information does not exceed £450. The Trust levies an administration charge of £50 for providing copies of health records for patients.

Martin Sykes Director of Finance 22 May 2014

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Strategic report - Our patients

The new Emergency Department (ED) and life-saving flights to Frimley

2012-2013 proved to be one of the most exciting years in the history of Frimley Park Hospital NHS Foundation Trust, with the successful completion of a new helipad, state of the art Emergency Department (ED) and a new cardiology wing.

The prominent £22m ED extension has completely changed the face of the hospital. With a two-theatre day surgery suite and a helipad, it was the biggest capital project since the hospital was built in 1974.

In 2013-2014, the new helipad received 30 arrivals and transfers of critically ill patients via the airborne emergency crews, continuing our commitment to provide the best emergency care to our local population and to people from as far and wide as the Isle of Wight, Oxford and Sussex.

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In July 2013, a remarkable chain of events including a 50 mile helicopter dash to Frimley’s heart attack centre saved the life of a Gatwick airport worker.

Geoffrey Constable, 56, from Crawley, remembers very little between starting work on a normal spring day and waking up several hours later at Frimley Park Hospital, some 50 miles away. He had suffered a near fatal heart attack at Gatwick Airport and was kept alive by his boss who performed chest compressions (CPR) on him for several minutes before an ambulance crew arrived.

They shocked him out of ventricular fibrillation– a dangerous heart rhythm – and put him on a ventilator as he was unconscious. He was then flown by helicopter to Frimley Park where a heart attack team reopened his blocked coronary arteries in a life-saving procedure 15 minutes after he landed on top of the hospital.

The air ambulance helicopter landed outside the office and Mr Constable was flown directly to Frimley Park. The 50 mile journey would have taken more than an hour by road but took just minutes by air. The air ambulance team chose to go to Frimley Park as it was the closest heart attack centre with a helipad on site. A trip to other neighbouring heart attack centres by road would have taken much longer and this option offered Mr Constable the best chance of survival.

Frimley Park is a 24-hour regional heart attack centre performing the emergency artery opening procedure known as primary angioplasty and is one of only few centres in the country with a helipad directly above the emergency department, offering rapid access. The fact that he walked out of hospital a week later is a tribute to the speed with which he received his treatment, the effectiveness of CPR performed by his boss, and the care he received from everyone through his patient journey.

Pictured above are Mr Constable (centre left) with Dr Vinod Achan (centre right) who led the cardiology team (some members also pictured) that helped to save Mr Constable’s life.

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Quality of care for our patients

Since 2010, all NHS foundation trusts have been required to publish an annual report on the quality of services they provide to patients. The Trust’s Quality Report 2013-2014 is an integral part of the Annual Report and Accounts and provides a detailed commentary on the requirements of the National Health Service (Quality Report) Regulations 2012 and Monitor’s Detailed requirements for quality reports 2013-2014.

Despite the busiest year the Trust has ever seen, we continued to push the boundaries of care for our patients. During 2013-2014, we celebrated some significant achievements.

Heart stroke and vascular centre

The Trust continues to strengthen hyperacute services and has launched the Surrey Heart, Stroke and Vascular Centre (2013-2014), providing cardiovascular services to patients in Hampshire, Surrey and Berkshire. The new centre brings together a number of specialities at the hospital to improve patient outcomes. The service was developed following recent guidance on best practice from the Department of Health. Conditions treated at the centre will include coronary heart disease, vascular disease, stroke and related conditions such as diabetes, kidney disease, hypertension and cholesterol management. Clinicians in the Cardiac Catheter Laboratory are now undertaking around 1,000 pPCI procedures and 2,500 angiograms on an annual basis. Furthermore, clinicians are undertaking more complex procedures, with 2013 seeing the first embolisation (deliberate blocking for a blood vessel for medical purposes) performed at the Trust.

Special care neonatal unit

We are delighted that our smallest patients and their parents can enjoy first class surroundings and care in our new special care neonatal unit (NNU). The NNU began welcoming patients in December 2013 and was officially opened by HRH, The Countess of Wessex in March 2014. The Countess was kind enough to express her thanks to the staff who looked after her when she had her two children at Frimley Park and said: “The service you provide is paramount and can literally make the difference between life and death, I can attest to that. It is rare to have the opportunity to thank people for the huge difference they have made at an important time in your life so I am so pleased to be here and to be able to say thank you in person.”

The Countess then spent time meeting new mothers and their babies as well as clinicians, neonatal nurses and pediatricians. The unit has 16 neonatal cots, eight designated for special care and eight for high dependency/intensive care. At a time when parents and families are especially anxious, the new facility are providing them with the best possible environment together with a high standard of care provided by the team.

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Care Quality Commission

In 2013-2014 the Trust received an overwhelmingly positive inspection report following the most rigorous inspection the Trust has ever undergone by the Care Quality Commission (CQC), maintaining our unconditional registration for all services. In line with the requirements of the Health and Social Care Act 2008 (the Act), the Trust continues to be registered with the CQC, the regulator of health and social care in England, without condition.

The CQC inspects NHS hospitals, reviewing key clinical services, looking at the care being delivered and considering:-

Is it safe?

Is it effective?

Is it caring?

Is it responsive to peoples’ needs?

Is it well led?

In November 2013, the Trust hosted a team of CQC assessors who carried out a new style, extensive inspection regime. The Trust had been selected by the CQC as an example of a ‘low risk’ hospital to take part in the first wave of the new inspections.

In December 2013, the Trust subsequently received an excellent inspection report from the Chief Inspector of Hospitals, Professor Sir Mike Richards. The Trust was recognised as having a passion for excellence, dedicated staff and a high standard of service. The report noted that staff working at the Trust are ‘overwhelmingly happy’ and described them as ‘a workforce of dedicated staff caring for people’.

The Trust is extremely pleased and assured that the conclusions the inspectors reached in this report were overwhelmingly positive. It is heartening and reassuring that the CQC recognised so much good practice and dedication from our excellent staff.

Inspectors spent two days on site and spoke with more than 80 patients and over 100 staff. As part of the inspection the CQC also held a public listening event to hear the opinions and experiences of patients and the public.

The CQC report picked out several areas as examples of best practice, including:-

Warm and sensitive interactions between staff and patients

Great teamwork and leadership in the emergency department (ED)

An open culture of learning

Good end of life care

Excellent education and support for junior doctors

Highly visible and outstanding leadership

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The Trust is pleased that the inspectors recognised the support and training our junior doctors receive. Ensuring junior doctors receive the best experience at the Trust helps us recruit and retain excellent doctors now and into the future. It is gratifying that Health Education Kent, Surrey and Sussex positioned us as the top hospital trust for junior doctors in 2013.

The CQC found there was no immediate improvement action required and recommended the Trust continued with work already commenced and implemented existing plans for dementia patients, review of ‘do not attempt resuscitation’ (DNAR) procedures and infection control protocols in the mortuary.

Pressure ulcers

As one of the Trust’s patient safety priorities for 2013-2014, the organisation has seen further significant reduction in the number of hospital acquired pressure ulcers, with a 39% reduction in the number of grade 2 pressure ulcers and a 55% reduction in grade 3 pressure ulcers. There have been no grade 4 (most severe) hospital acquired pressure sores for the past two financial years.

Dementia care

The Trust is passionate about improving dementia care and is a Dementia-Friendly Hospital. In June 2013 the Trust appointed a clinical specialist nurse in dementia to improve the quality of care and services to this group of patients, their families and their carers. The Trust considers that dementia awareness training for all hospital staff should be a priority to ensure a culture of good dementia care is embedded within the Trust’s care practices. The Trust is pursuing a number of initiatives including the provision of a specialised ward for dementia patients incorporating the latest care practices and technologies. In order to help meet the needs of carers and families, the Trust has initiated a drop in session where people can share their experiences and receive information about available health and community services and support.

Safeguarding adults and children

The Trust has appointed a Head of Adult Safeguarding to further identify patients who are potentially vulnerable. The Board receives annual reports relating to adult and child safeguarding. The Trust has developed a robust training strategy for both adult and child safeguarding and remains high on the Trust’s quality agenda.

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Increases in nurse staffing levels

Nurse staffing levels have been reviewed for every ward and a further £2m invested to move to a 1:8 nurse to patient ratio for morning and afternoon shifts and a 1:10 ratio for night shifts on all adult wards. Higher staffing ratios are already in place in critical areas as defined by the Intensive Care Society. A total of 330 nurses were recruited in 2013-2014. All ward staffing levels will be on public display from June 2014.

Reducing harm and mortality

We made significant progress towards our target to reduce patient harm by a further 15% by the year 2015-2016 (after successfully reducing harm rates by 53% in the period 2009–2013). During 2013-2014 we further reduced harm to our patients by an average of 20%. Mortality and safety ratings continue to rank among the top five hospitals in England.

We were awarded Trust of the Year (South of England) by the Dr Foster Guide for mortality and safety. In 2012 Dr Foster rated the Trust as runner up Trust of the Year.

Customer service strategy and training

We implemented the Customer Service Strategy which reflected the Trust’s values (committed to excellence, working together and facing the future). The success of the strategy has been evidenced by the results of a local question added to the national staff survey. A very gratifying 92% of staff articulated that they understood the new values.

Additionally, almost all managers and more than 1,400 front-line staff have received customer service training over the last 12 months.

Listening to patients

Patient and public feedback is essential to ensure that the Trust develops and improves services to meet the needs and expectations of our patients. The Trust has a number of systems in place for obtaining patient feedback.

Governor and health event meetings

Governors continued to hold local health events in their constituencies, which have proved to be very popular. On average 144 Trust members and members of the public attended the 10 events in 2013-2014, with 250 people joining the respiratory event at Rushmoor in September 2013. They are an excellent opportunity for the community to find out more about services provided by the hospital and to meet and question governors, directors and managers. Each event includes a presentation from a consultant or other specialist, and keypad technology is used to ask questions to the audience, with the responses fed back to relevant managers and departments.

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Patient Experience and Involvement Group (PEIG)

As a sub-group of the Council of Governors (CoG), the PEIG meets quarterly to provide feedback to the Trust and the CoG on matters relating to service developments and patient experience.

The PEIG receives presentations on new developments and reviews patient satisfaction surveys. Group members take part in quality assurance walkabouts where there is an opportunity to review ward clinical indicators, visit hospital wards, and talk first hand with patients about their experiences. This year the group focused on:

Improving the care and experience for patients who are being discharged from hospital (including transport services)

Reducing noise at night

Ophthalmology department service improvement

Communication around the hospital

The PEIG continues to flourish and is looking forward to welcoming new members who will continue to focus on improving the experience of patients. In the coming year the Trust will be welcoming a representative Healthwatch to the PEIG.

National surveys

The Trust conducts a number of surveys to monitor and help sustain very high levels of patient satisfaction.

The Trust’s patient feedback system

Once again we are very proud to say that over 99% of our patients’ rate their care as good, very good or excellent and 99% would ‘definitely’ or ‘probably’ recommend us to their friends and family (Trust’s own patient satisfaction survey).

National Inpatient Survey

During 2013-2014 the Trust participated in national surveys relating to inpatient and cancer services. On behalf of the CQC in August 2013, some 850 Frimley Park patients were approached to complete the survey as part of the National Inpatient Survey by the CQC, which was published in April 2014. More than half (51%) responded, better than the national average of 49%.

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Patients praised levels of privacy, the quality of food and access to information following treatment. Results placed the Trust in line with our counterparts, scoring upwards of 80% across eight of the ten core assessment areas. Patients said the Trust excelled, in particular, in ensuring waiting times were kept to a minimum and that admission dates were adhered to. Those using newly refurbished ED said they were satisfied with the information available on their condition and treatment and stated that there was adequate privacy throughout the department.

The report was presented in different ‘domains’ or aspects of care, where questions relating to each domain have been compiled together to give a single composite score. The CQC divided responses into 10 broad categories. Overall The Trust scored ‘about the same’ in comparison to other Trusts in all 10 categories.

National Inpatient Survey results for Frimley Park Hospital NHS Foundation Trust 2013

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Within those 10 categories the Trust performed ‘better’ than other Trusts for the following aspects:

For being treated with dignity and respect overall

Enough privacy and dignity in the ED

Admission dates were not changed

Hospital food was described as good

Availability of hand gels for patients and visitors

For patients receiving an explanation they could understand from the anaesthetist or another member of staff about how they would be put to sleep or their pain controlled

For patients being given written or printed information about what they should or should not do after leaving hospital

For patients being given clear written or printed information about medicines (those given medicines to take home)

For ensuring letters between the hospital doctors and family GP were written in a way they could understand

Friends and Family Test (FFT)

The Friends and Family Test (FFT) was introduced in April 2013 for inpatients and patients who attended Accident & Emergency (A&E). The Trust is very grateful to all those patients who have taken the time to give us their feedback.

In line with the national roll out of the FFT to include other patient groups, in October 2013, the Trust introduced the FFT for maternity patients. The first six months results were excellent with 99% of our patients telling us that they would be ‘extremely likely’ or ‘likely’ to recommend our maternity services to their friends and family.

The Trust has fully embraced and embedded the FFT, which is reflected in the exceptional performance both locally and nationally in terms of response rates and scores.

The ‘real time’ feedback afforded by the FFT has facilitated quicker response times to issues or concerns highlighted by our patients. Trends in feedback and negative responses that have occurred throughout the year have been scrutinised at the monthly Patient Experience Forum, to ensure changes in practice are implemented as a result.

The feedback has also highlighted the excellent care delivered on many occasions by our teams, demonstrating the embedding our values and the dedication of our staff.

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Quality assurance walkabouts

Based on the 15 steps challenge, which look at care settings from a patient perspective, the Quality Assurance Walkabouts have continued throughout the year. The walkabouts are led by an executive director, attended by both a non-executive director, a member of the CoG and supported by a member of the quality team.

Prior to the walkabout, intelligence regarding any emerging trends in complaints and incidents is provided along with outcomes of both the FFT and local in-patient surveys to give a detailed picture of the ward performance in respect of patient safety and experience.

During the walkabout observations are noted and patients and staff are asked directly about their experience on the ward. Feedback is collated immediately after the walkabout session ensuring that examples of good practice that have been identified, suggestions for improvement, and any immediate issues requiring action are provided directly to the ward.

It is envisaged that in 2014-2015 the quality walkabouts will be further embedded within the organisation by ensuring that regular feedback is cascaded to Trust management via summaries being presented as part of the monthly Patient Experience and Complaints forum.

Patient Advice and Liaison Service (PALS)

The PALS service continues to offer frontline support and advice to those wishing to raise a concern. It has a strong visible presence, with an office next to the hospital’s main reception, and the PALS email address is well advertised online and elsewhere.

There were 2,415 contacts to PALS in 2013-2014, an increase of 42% on the previous year (2012-2013: 1,392). Of these, 885 contacts were ‘concerns’, compared with 553 in 2012-2013 (a 37% increase). The PALS team also links with wards through volunteers helping to carry out the internal patient satisfaction surveys. The team also offers advice to staff and service users in resolving informal issues, and signposting enquiries to other agencies and services. PALS also has a variety of other roles, for example helping departments translate documents, witnessing wills and maintaining the distribution network of Trust information leaflets.

Handling complaints

The Trust makes sure it learns from the complaints it receives. They drive service improvements and changes in practice. Every effort is made to resolve issues locally in a way that is acceptable to the complainant. Local resolution meetings are held where complaints are complex or where they raise more serious concerns.

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In 2013-2014 the Trust received 382 formal complaints (2012-2013: 431), a decrease of 11% compared with the previous year. The actual ratio of complaints against activity fell from 0.06% of overall activity in 2012-2013 to 0.05% in 2013-2014. The Trust endeavours to respond within 25 working days to all complaints. Complaints have become more complex as services are expanded and often involve different agencies or are across local trusts. The Trust’s complaints forum continued to meet monthly to monitor compliance against the NHS complaints regulations and the CQC outcomes. Representatives from each directorate presented individual complaints to ensure learning was shared across directorates. Complaints were also discussed at local clinical governance meetings. Complaints may highlight a need to change a practice or improve a service in an individual area. When identified, a change in practice will be implemented to avoid recurrence. Learning is shared at local level through our head of education and the practice development teams. Individual complaints are used in training at preceptorship or junior doctors’ training. They are also shared at specialty level meetings and reviewed at relevant forums such as the dementia group or end of life care forum. Social Media

Informal feedback and engagement is also conducted with the Trust’s social media community, mostly through its growing Facebook and Twitter following which has expanded to over 6,000 followers in total in three years. Additional Trust accounts set up in 2013-2014, such as Facebook pages for Maternity and fundraising, have attracted more followers in their own right. Innovation and change In 2013 the Trust has developed a new Innovation and Change team to support the Trust’s corporate and operational strategy. This included delivering sufficient financial benefit without undermining quality, as well as developing new services and implementing new ways of working, both internally and with a range of partner organisations.

In order to meet tough efficiency targets as part of the £15bn to £20bn economy drive across the NHS, the Trust has undertaken a successful cost improvement programme, which delivered savings of £8m in 2013-2014 (2011-2013: £20m).

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The Innovation and Change work programme is made up of the following.

Programme Description of programme

Length of stay Reducing unnecessarily long stays in hospital and ensuring patients receive the most effective care at the right time and in the right place.

Outpatients Providing exemplary outpatient services across all sites.

Medical model Redesigning medical services to achieve consultant delivered services.

Urgent care Ensuring the Trust is in the best place to manage demand on its emergency services and provide the best possible care and patient experience.

Patient flow Delivering initiatives to improve the flow of patients throughout the entire hospital system.

Readmission Reducing the number of patients who find themselves being readmitted to the hospital following discharge.

Integration Working with partner organisations on a range of projects to improve pathways and patient care, not only within the hospital, but more broadly across the local health economy.

Non NHS income Further developing research and development and Parkside, our private health care service.

New business Offering our services to people who live on the edges of our current catchment population.

Much of the work supported by the Innovation and Change team supports operational teams in the delivery of business as usual. However increasingly there is a focus on working with our partners from other organisations as well as more widely to explore how things can be done differently.

In addition to the work being done on the work streams above, the Innovation and Change team is also involved in supporting a number of other Trust-wide projects. These other work streams, on the following table, describe core functions for departments in the Trust, but the involvement of the Innovation and Change team ensures that the links are made with other areas of the Trust’s operations.

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Informatics Maximise the use of technology as an enabler to underpin transformational change, and its associated benefits across the organisation

Medicines Procurement and transfer to homecare benefits

Carbon strategy Benefits from introducing sustainable energy efficient solutions

Income improvement

Benefits from improved identification of patient pathways and coding

The Trust is committed to innovative change, putting patients at the centre of all that we do, in preference to sustained cost cutting and will continue to monitor the success of all programmes of work and how these impact on patient experience, Trust performance and staff feedback. New ideas and changes will emerge and the Trust will work with patients, commissioners, social care and other providers to ensure the maximum benefit is achieved.

Consultant delivered services

The Trust has invested in consultant delivered front line services and already has more of the most senior doctors on site than almost any other acute Trust of its size. For example the Trust has established or is close to establishing the following services:

Specialty On-site consultant cover

Emergency department

8am to midnight week days, 8am-10pm weekends

General medicine 12.5 hours x 2 consultants week days, 12hrs a day weekends

Radiology 8am to 8.30pm week days, 4hours Saturday

Critical care 12 hours a day week days, 8am to 4pm weekends

General surgery 8am to 8pm week days , ward round and operating at weekends

Trauma 8am to 7pm consultant delivered week days, 9hours Saturday and 5hours Sunday

Paediatrics 8.30am to 7.30pm week days, on call plus ward rounds at weekends

Maternity 8am to 10pm Monday to Friday, 6hours Saturday and Sunday

Cardiology Ward round 7 days a week plus pPCI 24/7

Emergency theatre 8am to 7pm weekdays, on call at weekends

Vascular & interventional radiology

24/7 consultant delivered service for emergencies

Stroke 24/7 consultant delivered service for acute stroke patients

Respiratory medicine

Daily consultant review of inpatients and Medical ADU. General physicians provide consultant review of inpatients admitted to MAU at weekends.

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Strategic report – Our people

Staff engagement

As a major local employer, Frimley Park Hospital Foundation Trust (the Trust) is committed to the principles of partnership working and staff engagement.

The Trust strongly believes that involving its staff in decision making processes draws upon their knowledge and expertise from their work environment to generate ideas that will help develop and modernise NHS services.

The Trust has a range of standing and project groups and committees, which seek to involve staff in making decisions about future developments. For example, the Trust has a Staff Council which meets regularly. It provides an effective method of regular consultation between managers and staff representatives and is intended to form the basis of a constructive and co-operative approach towards achieving corporate goals. The Staff Council also reviews and approves staff bids for funds from the Improving Working Lives lottery fund. This fund uses the proceeds of a monthly staff lottery to pay for a range of items to improve the working environment, from a new kettle for a staff rest room to funding for a new cycle pathway for staff.

The Trust also has other consultative bodies to discuss specific areas of joint interest with staff representatives such as the Local Communications Networks, the Health and Safety Committee, and the Equality and Diversity Steering Group.

Mechanisms in place to monitor and learn from staff feedback include:

Business planning within directorates, involving managers and staff

The clinical governance infrastructure, which enables multidisciplinary discussion of clinical issues and service improvement

Regular face-to-face update briefings from the Chief Executive, executive director question and answer sessions and team briefings through which key points are cascaded to teams and departments, with the opportunity for staff to ask questions and raise concerns

A fortnightly newsletter to which all staff are encouraged to contribute

A well-used intranet which includes departmental mini-sites and a live news feed incorporating a comments section allowing staff to feedback on items of staff news

Staff following the Trust on its official Facebook and Twitter sites and contributing to exchanges as appropriate

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Investors in People assessment framework including feedback from a representative group of staff on the effectiveness of the Trust’s arrangements for communicating with staff

The annual NHS Staff Survey and action planning

Annual appraisal for all staff

National Staff Survey

The results of the 2013 National Staff Survey, carried out across the NHS on behalf of the Care Quality Commission (CQC), once again returned excellent results for the Trust, reflecting a highly motivated and professional workforce. Staff in NHS trusts were questioned anonymously from October to December 2013 and the results were published in February 2014.

The Trust scored particularly well on staff engagement, recommending their hospital as a place to work and receive care, job satisfaction, training, support, work-life balance and team working. It was also encouraging to note that staff continue to give the Trust one of the best scores in the country for the fairness of its systems for staff reporting incidents.

The 28 key findings of the Trust’s 2013 Staff Survey results compared to other acute hospital trusts were summarised as follows:

17 (2012: 15) were in the best 20%

6 (2012: 6) better than average

3 (2012: 3) at the average

2 (2012: 2) worse than average

0 (2012: 2) in the worst 20%

In addition, two of the key findings had significantly improved since 2012 and none had deteriorated.

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National staff survey results

Response rate

2013 2012

Trust rate Comparative rate

Trust rate

Comparative rate

Change

46% Below average

58% Best 20% -12%

Top four ranking scores

2013 2012

Trust National average


Change

Staff recommend Trust as a place to work or receive treatment

4.06 3.68 4.07 3.57 -0.01

Fairness and effectiveness of incident reporting procedures

3.70 3.51 3.68 3.50 0.02

Effective team working 3.90 3.74 3.85 3.72 0.05 % of staff saying hand washing materials are always available

74% 60% 70% 60% -4%

Bottom four ranking scores

2013 2012



Change

% of staff working extra hours

70% 70% 74% 70% -4%

% of staff appraised in past 12 months

81% 84% 74% 84% 7%

% of staff feeling pressure in last 3 months to attend work when feeling unwell

28% 28% 31% 29% -3%

% of staff experiencing discrimination at work in the last 12 months

12% 11% 12% 11% 0

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Future priorities and targets

The results of the staff survey have been used to help develop an action plan for the year ahead. It includes the following:

To look at ways of continuing to reduce the number of staff who are working extra hours from 70% to 67%

To maintain the number of staff appraised at more than 80%

To review and address the incidence of work-related stress

To investigate and address the reasons for experience of discrimination at work

In 2013-2014 we also made significant progress in improving quality for our staff. We were delighted to receive confirmation from both the Care Quality Commission and the national staff survey, that our staff are ‘overwhelmingly’ happy working for the Trust and are passionate about caring for our patients, their families and carers.

Equality and diversity

The Trust publishes annual employment and service information, thereby demonstrating compliance with the Public Sector Equality Duty. Equality objectives to support compliance with the Public Sector Equality Duty were published in April 2012 and replaced the Trust’s single equality scheme 2010-2013. Full reports regarding equality and diversity at the Trust can be found on the Equality and Diversity page on the Trust’s website.

Disabled staff

The Trust was assessed in May 2013 as compliant with its commitments as a Positive About Disabled People symbol user, which includes the following:

Interviewing disabled applicants who meet the minimum job criteria

Consulting annually with individual disabled staff through the appraisal process about how they can develop and how the Trust can support them

Making every effort to redeploy staff who become disabled

Raising awareness of disability amongst staff

Monitoring and communicating annually achievements in relation to the commitments

In the year to 31 March 2014, the Trust received 377 applications for jobs from disabled applicants. Of these, 99 disabled applicants were shortlisted and 21 disabled inter-viewees were appointed.

To encourage disabled applicants to apply for jobs, the Trust will continue to take positive action to target disabled applicants through Job Centre Plus and the Shaw Trust.

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Encouraging employment

Community working – schools

The Trust continued to work in partnership with local schools and colleges and this included attending a number of their careers days as well as hosting the annual ‘Taste of Frimley’ event for local students. The event proved to be as popular as in previous years, with students enjoying the tours to various departments across the Trust, demonstrations of equipment in a clinical setting, and listening to presentations on careers in professions such as midwifery.

The Trust also set up a short programme for students interested in a nursing career so they could spend time on the wards to give them a good insight into the profession prior to their applications for nurse training.

The Trust offered 130 placements to give students the opportunity to experience and observe a working environment within a hospital for them to be better informed about their choice of career.

Recruitment

There were a number of initiatives taken to attract and retain high calibre staff over the last year. These included further programmes for care assistants across the Trust where those selected and appointed from the recruitment days joined the Trust as a single cohort with a specially designed programme to support their introduction and development. The Trust ran regular recruitment mornings at weekends throughout the year to attract general and specialist nurses. On occasion these events were expanded to include occupational therapists and biomedical scientists. The Trust also recruited over 35 generalist nurses from abroad who joined us in three small cohorts.

Of the total employees at the year-end, 3,599 (80%) were female and 905 (20%) were male employees.

Medical Staffing

The number of consultants has increased by 10, to nearly 200 over the year, in support of the Trust’s strategy of focusing on hyperacute services and developments in specialties. This has included emergency medicine, anaesthetics, surgery, urology, ophthalmology, paediatrics, and radiology.

The numbers of trainees allocated to the Trust by the deaneries has fluctuated, and this has presented some difficulties in recruitment especially at middle grade and registrar levels. Some specialties are listed as ‘shortage occupations’ making recruitment of non-European Union doctors easier.

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As in previous years the Trust has managed rotas for junior doctors within the 48 hour European Working Time Directive limit despite occasional staffing difficulty. Spending on locum doctors increased in the year due to activity pressures. Occupational Health and Safety Services In the past year the Occupational Health and Safety Department has played a major role in several projects. For example:

A review of the Trust’s CCTV system and a site survey was undertaken in partnership with local police counter terrorism advisers to ensure compliance with new government guidance on site safety

Conflict resolution training for staff was improved and a significant drop (15%) in reports of physical violence was noted over the year

In the autumn of 2013 the department ran another successful staff flu vaccination programme. 2,518 workers with direct patient care had the vaccine, an increase of 4.4% on 2012-2013. Once again the Trust was one of the best performing in the south east region

The Trust’s Smoke Free Site Policy was reviewed and Frimley remains smoke free across the whole site. This work was supported by both Surrey Heath Environmental Health Department and the local Smoking Cessation Services, who provided smoking cessation clinics for staff

A staff health fair held in February 2014 was well attended with many exhibits promoting health and wellbeing, with free cholesterol testing being especially popular with staff

In response to new regulations requiring hospitals to assess the use of all sharp devices, such as needles and scalpels, the service has helped all relevant departments to adopt safer systems of practice, wherever possible.

In association with the Trust’s Informatics Department a programme was undertaken to tag specialist manual handling equipment electronically, so equipment is less likely to be lost and can be tracked and found quickly in an emergency.

The steady decline in the number of health and safety related incidents reported over the past five years has continued. In addition, the number of incidents reported to the Health and Safety Executive (HSE) remains very low and there were no major incidents or dangerous occurrences that required reporting under relevant legislation. Ill heath retirement

During the course of the year, no additional pension costs were incurred through early retirement due to ill health.

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Strategic report – Working in partnership

Frimley Park Hospital NHS Foundation Trust (the Trust) sets great store by maintaining good working relationships with partner organisations. Here are some of the key ones that help to make the Trust a success.

Ministry of Defence

The Ministry of Defence Hospital Unit (MDHU) has been located at Frimley Park Hospital since 1996. The military staff are fully integrated in the clinical departments and specialties.

Military clinicians treat both civilian and military patients alongside their civilian colleagues. Military patients have access to the full range of clinical services at Frimley Park Hospital. Treatment for civilian and military patients has continued without disruption despite the various ongoing requirements for military medical staff to deploy on operations, including Afghanistan.

The Trust, its staff, and patients benefit from the skills and expertise the service personnel gain on operational tours. In return the MDHU benefits from comprehensive training and experience for its medical, nursing and allied healthcare professional staff. MDHU personnel have undertaken a range of professional training courses at the Trust, the Royal Centre for Defence Medicine and other national centres of excellence. The military influence has also benefited non-clinical skills in the Trust through the recent development of a Ward Management Leadership programme.

The MDHU Commanding Officer, Lt Col Andrew Day OStJ RAMC has regular review meetings with the management of the Trust regarding the military staff working at the hospital and MDHU senior staff regularly attend senior management meetings at the hospital.

The military is represented on the Council of Governors (CoG) by the Regional Clinical Director for Defence Primary Healthcare, South Region, who represents the views of commanders, military patients and primary care clinicians who refer patients to the Trust. This was Surgeon Captain Rob Ross MBE FRCS Royal Navy until 31 August 2013 when he was replaced by Surgeon Captain Fleur Marshall MRCGP Royal Navy.

Surrey Pathology Services

Partnership Pathology Services (PPS), a joint arrangement between the Trust and the Royal Surrey County Hospital NHS Foundation Trust, was established in 1998. On 1 April 2012 another partner, Ashford and St Peter’s Hospitals NHS Foundation Trust, joined the venture to form Surrey Pathology Services (SPS).

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During the course of the year SPS has been working with Ashford and St. Peter’s NHS Foundation Trust’s pathology department to develop the new integrated pathology service across West Surrey, supported by all three trust boards. The new service is more efficient and provides high quality services to all its users, building on the foundations of PPS and supporting the national strategy to consolidate pathology services.

SPS has continued to expand its business in both the public and private sectors and notably provides specialist services to Brighton & Sussex University Hospitals, Nuffield Healthcare and Spire Healthcare across the UK.

SPS has been visited by its accrediting body, Clinical Pathology Accreditation Ltd, (CPA) and has also had successful inspections from the Medicines and Healthcare Products Regulatory Agency for Blood Transfusion, the Human Tissue Authority, the Human Fertilisation and Embryology Authority and the UK Inspection of Bowel Cancer Screening.

Specialist services continue to be developed, notably molecular biology, virology, immunology, and the South of England Bowel Cancer Screening Programme. The introduction of additional consultants and clinical scientists has resulted in these specialities gaining a regional profile.

SPS is one of the largest pathology services in the UK and has a reputation as a leader in the services offered, continuing to develop internal services and strategic partnerships with other NHS and private organisations, resulting in significant benefits for patients, commissioners and the trusts.

Local strategic partnerships

The Trust continues to work in partnership with the local clinical commissioning groups, social service departments, community health providers and the local mental health trust.

The Trust is committed to developing and enhancing the model of care for frail older people. As part of this the Trust has been working closely with Local Nursing and Care Homes supporting training initiatives to improve health and wellbeing. Local Nursing and Care homes are now offered relationship managers to ensure close partnerships are developed and maintained.

The Trust’s commitment to provide a dementia-friendly environment and specialist hospital ward to enhance the care and experience of both patients with dementia and their carers continues. The Dementia Care Team now hold regular café afternoons for carers to come along for support and to enable them to have a voice in shaping our services.

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Volunteers

The number of volunteers working in the Trust continues to increase every year. The support they provide is invaluable, and the Trust is developing a volunteering strategy to recognise their contribution and further encourage and engage the voluntary sector.

Our volunteers have been key in supporting our patients to participate in patient experience surveys, enabling them to have a voice about how we deliver our services and to highlight where we can make improvements to ensure we can fulfil our commitment to excellence.

Our volunteers have also provided companionship and assistance for patients at mealtimes to encourage them to eat well.

They continue to manage the bookshop and hospital patient library, support main reception, the Eye Treatment Centre, help at the breast care clinic and Radio Frimley Park, and significantly contribute to and organise fundraising events. The Trust’s volunteers also assist in minor repairs of hearing aids by visiting residential homes so that patients do not need to come to the hospital. The Trust also has a vast number of chaplaincy volunteers supporting patients.

Fundraising

Saving Tiny Lives appeal

The saving Tiny Lives appeal exceeded its £150,000 target and raised over £175,000, allowing us to purchase a large range of additional equipment for the upgraded special care neonatal unit. The equipment purchased included:

Six Vapotherm advanced respirators

Three high dependency cots

Four state of the art monitors

A transfer incubator and ventilator

A cerebral function monitor

Light therapy systems

Four neonatal resuscitators

Breast Care appeal

The Trust launched a new Breast care Appeal in the autumn 2013 to raise £750,000, which the Trust will match fund up to a further £750,000. The aim of the appeal is to provide a £1.5m dedicated breast care centre with state of the art 3D diagnostic imaging equipment to provide the best possible care for patients, over and above the minimum standards required by the NHS. The Frimley Park Hospital Charity is appealing to the community to help raise the money over the next three years.

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Fundraising events A number of fundraising events in and around the hospital were held and the Trust is grateful to all volunteers for their help. Some of the ways in which the community has helped the Frimley Park Hospital Charity to raise money for its appeals include:

Over a thousand people took part in the annual 10k Road Race and 2.5k Fun Run, raising more than £35,000 for key charitable projects, including the Saving Tiny Lives Appeal. The 2013 event also included a race on inline skates. It proved so popular that it will be included again in 2014 as one of the main races.

The gentleman and lady captains of East Berks Golf Club selected the Heart 2 Heart Appeal as their charity for 2013. Following a visit to the new cardiac cath laboratory, the captains chose to raise funds for a new cardiac monitor and Dinamap. This provides powerful high performance constant monitoring of a patient’s vital signs as well as the depth of anesthesia. The club presented the charity with a cheque for £24,000 for the Heart 2 Heart Appeal in February 2014.

KatCanDo raised over £14,500 which purchased a new trans-oesphageal echo (TEO) which is being used by the colorectal team for the treatment of early rectal cancer at Frimley. This second TEO supports the national bowel cancer screening programme, referring many more patients with early rectal cancer to Frimley.

A team of 21 mums, dads, hospital staff, and supporters abseiled 100 metres down Portsmouth’s Spinnaker Tower and raised over £4,000 for the Saving Tiny Lives Appeal. The event was organised by Emma Adams from the emergency department.

Sainsbury’s at The Mall in Camberley donated over £2,000 following a year-long partnership with the Frimley Park Hospital Charity, which was raised by collection tins, skydiving in-store events and a Christmas event.

Local couple James Saunders and Claire Savage took part in the ‘Run to the Beat’ half-marathon and raised over £2,000 for the Saving Tiny Lives Appeal.

12 local schools together raised over £6,000 from a number of events across the academic year for the hospital charity.

Stroke unit staff and friends raised over £1,500 by climbing the four highest peaks in the Lake District to fund specialist seating in the stroke unit and a second computer on wheels.

Emergency department staff took on the Nuts assault course challenge and raised £500 for the ED bereavement fund.

The Trust’s themed Christmas party ‘To Russia with Love’ held at Five in Farnborough raised £8,500. The event was very successful and will repeated in 2014.

The Sixth Form College, Farnborough, raised around £1,700 from a ‘Pink Day’.

Midwife Anna Holland ran the London Marathon, raising over £1,400 for the Saving Tiny Lives Appeal and Marie Curie Cancer Care.

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Female impersonator Mr Ken Dee returned to the stage at the Princes Hall, Aldershot, for a special performance of his ‘Musicals, Dance and Divas 2’ show in aid of Frimley Park Hospital Charity’s Breast Care Appeal.

A Christmas toy run saw a parade of hot rods, custom, classic and American cars cruising to the hospital with gift-wrapped presents and a £1,000 donation.

More generous donations of presents, games, toys, DVDs, Christmas stockings, and cuddly toy dogs were brought in by supporters including Access Storage, staff from BHS in Camberley, Frimley Lodge Miniature Railway, Collectively Camberley, Morrisons in Farnborough, Eagle Radio, the A5 Scooter Club and a former children’s ward patient;

Fundraising manager Nick Le Resche had his first haircut in 12 years. He had the chop in front of friends, family and colleagues at Frimley Park Hospital, raising nearly £1,000 for the hospital charity’s Breast Care Appeal.

The last group of dental hygiene students to graduate from Keogh Barracks presented a cheque for over £1,200 to the Trust’s Saving Tiny Lives appeal.

Frimley Park’s exchange programme with Kitwe Central Hospital in Zambia continued as part of the World Health organisation’s Vision2020 Link scheme. Since its inception in 2011, exchange visits by each hospital’s ophthalmology staff and management have taken place enabling the Trust’s clinicians to share best practice and the latest techniques and in return, benefit from seeing innovative methods employed in Kitwe to make the best use of limited financial resources. The Link programme has attracted public support through the Frimley Park Hospital charity.

WRVS and Bookshop

The Trust has continued to benefit from support from the WRVS and is working with the charity to look at how the money can be used to support the Trust’s dementia strategy together with the purchase of specialist chairs for stroke patients.

Community engagement

During the year the Trust continued to develop its community engagement strategy to promote good relationships, communication, and collaboration with the wider community. It focused on engaging people through foundation trust membership, fundraising, and some aspects of volunteering.

The overarching aim is to maximise community support for the Trust and to improve its understanding and response to social and community issues. The Trust has implemented a number of initiatives in the year. Some examples of these were:

A Nepalese ‘Health and Wellbeing Showcase Event’ in conjunction with Macmillan which took place in November 2013 at the Village Hotel, Farnborough and was attended by over 100 community members.

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A meeting with a local group in Farnborough (Miscellaneous Club) where 45 deaf people gave feedback about the provision of services for that community.

Open Sight Group (blind or partially sighted people) – a survey has been modified by this local group and an officer commissioned to visit 10 members and patients in their own homes to gain their views about Trust services and improvements they would like to be made.

A programme to train 20 members of staff to a high standard to act as interpreters for our patients.

A pilot programme for volunteers from the Samaritans to be available in our Emergency Department to help distressed patients.

The Trust will continue to monitor the outcomes from the strategy in the coming year.

Further information on engagement with members can be found on pages 91 to 97.

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Strategic report – Sustainability report Introduction

Sustainability has become increasingly important as the impact of peoples' lifestyles and business choices are changing the world in which we live. In order to fulfil its responsibilities for the role it plays, the Trust has the following vision statement located in the Carbon Management Plan (CMP) 2010-2015:

‘The Trust will be a leader in the community and empower staff during the carbon

reduction journey, whilst offering safe, personal and local healthcare’ Policies

In order to embed sustainability within our business it is important we explain where in our process and procedures sustainability features.

Area Is sustainability considered?

Travel Yes

Procurement (environmental) Yes

Procurement (social impact) Yes

Suppliers' impact Yes

In August 2013, the Trust used the Good Corporate Citizenship (GCC) tool to help assess our commitment to corporate social responsibility, scoring 42 (21 is the national average taken from 94 participating acute trusts, with the highest being best and ranging from one to 100). This will be used as a building block for the production of a sustainable development management plan (SDMP), which will be produced during 2014 to succeed the CMP and continue our plans for a sustainable future.

Summary of GHG emissions

Since October 2013, the Companies Act 2006 (Strategic Report and Directors’ Report) Regulations 2013 has required all companies to report on their greenhouse gas (GHG) emissions, which are either direct or indirect and which are divided further into scope 1, scope 2 and scope 3 emissions. This does not apply to foundation trusts. However, the Trust has chosen to disclose the information.

Direct GHG emissions are emissions from sources that are owned or controlled by Frimley Park Hospital. Indirect GHG emissions are emissions that are a consequence of the activities of the Trust but that occur at sources owned or controlled by other entities.

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GHG emissions (tonnes CO2 equivalent, or tCO2e) summary

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

Scope 1(1) 3,296 3,425 5,393 6,853 7,175 7,370 7,394

Scope 2(2) 3,543 4,087 3,485 1,444 1,066 921 1,620

Scope 3(3) 40,069 49,181 50,268 51,553 60,777 60,310 60,369

TOTAL 46,909 56,693 59,146 59,850 69,018 68,600 69,382 (1) Direct emissions controlled by the Trust arising from gas use in buildings, Trust vehicles and anaesthetic gases. (2) Indirect emissions attributable to the Trust due to its consumption of purchased electricity. (3) Other indirect emissions associated with activities that support or supply the Trust’s operations within

procurement, travel, waste, water and transmission of energy supplies. Scope 3 emissions account for 87% of the Trust’s total CO2 emissions.

The above table shows an increase in emissions from 2007, a direct result of the hospital’s growth relating to increased floor space, staff and patient activity (outlined in the table below). Scope 1 and 2 figures have been generated using actual figures, and indicate where the Trust has made progress on reducing electrical consumption (scope 2) and where the Trust installed a combined heat and power (CHP) plant in 2010 to utilise gas to produce electricity (scope 1). CO2 emissions and cost per unit of electricity are significantly more than gas, hence the focus on reducing electrical consumption within the CMP.

Performance

Organisation

Since the 2007 baseline year, the Trust has undergone significant change in both floor space and staff members.

Context info 2007/08 2011/12 2012/13 2013/14

Floor space (m2) 66,501 73,720 80,032 *80,032

Number of staff (at year end) 2,821 3,481 3,587 3,830 * Information unavailable but will be similar to previous year

As a part of the NHS, the Trust is committed towards the goal set in 2009 to reduce the carbon footprint of the NHS by 10% (from a 2007 baseline) by 2015. It is our aim to reduce our carbon emissions by 15% by 2015 using 2009/10 as the baseline year.

Energy

FPH spent £1,678,781 on energy in 2013-2014, which is a 7.5% increase on energy spend from last year. The Trust has undergone significant development over the past two years, with a new ED, day surgery and helipad building, a new cardiology centre and a 34 bed ward currently under construction. Emissions associated with the new buildings were not included in the original targets for the CMP 2010-2015 and the general increase since 2012 is evident, with approx. 450 tCO2e accounted for in electrical use within the new buildings.

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-

2,000

4,000

6,000

8,000

10,000

12,000

2011/12 2012/13 2013/14

Carb

on (t

CO2e

)

Carbon emissions - energy use

Gas Electricity

The Trust’s 1.3MW Trigeneration CHP has had a significant impact on energy use and saved the Trust over £380k and 1,172 tCO2e in 2013-2014. 0.26% of our electricity use comes from renewable sources.

The Trust has carried out many energy reduction projects during 2013-2014, including re-insulating the main boiler rooms, LED lighting upgrades in the car park and internal departments, installing the infrastructure to utilise low grade heat from the CHP, lighting sensors and the implementation of the successful behaviour change programme ‘Operation TLC’ in January 2014.

Waste

The Trust introduced an offensive waste stream during 2013-2014, diverting 56 tonnes from the non-burn disposal category. An on-going waste bin reduction programme has also been introduced to collect mixed recycling and create more space within departments, resulting in increased awareness, improved recycling figures, and a saving in CO2e.

Resource 2011-2012 2012-2013 2013-2014

Gas use (kWh) 37,573,376 38,806,445 39,421,795

tCO2e 7,678 7,930 8,363

Electricity use (kWh) 10,944,880 10,931,544 11,516,787

tCO2e 1,322 1,009 1,793

Total energy CO2e 9,000 8,939 10,156

Total energy spend (£) 1,408,664 1,561,474 1,678,781

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-

200

400

600

800

1,000

1,200

1,400

2011/12 2012/13 2013/14

Wei

ght (

tonn

es)

Waste Breakdown

Recycling

WEEE

High Temprecovery

Non-burndisposal

Landfill

15%13%

72%

Proportions of carbon footprint

Energy

Travel

Procurement

Water

The Trust's water consumption has remained fairly consistent since 2007-2008 with no big increase as a result of extra floor area or patient activity. The Trust has partnered with Aquafund to look at billing and potential initiatives to reduce water consumption.

Water 2011/12 2012/13 2013/14

Mains m3 107,045 102,382 106,493

tCO2e 98 93 97

Water & Sewage Spend £153,857 £159,542 £170,228

Modelled carbon footprint

The information provided in the previous sections of this sustainability report uses the Estates Return Information Collection (ERIC) returns as its data source. However, we are aware that this does not reflect our entire carbon footprint.

The following graph uses a scaled model based on work performed by the NHS Sustainable Development Unit (SDU) in 2009-2010, resulting in an estimated total carbon footprint of 69,139 tCO2e for the Trust.

Waste 2011-12 2012-13 2013-14

Recycling (tonnes) 624 359 426

tCO2e 13 8 9

WEEE (tonnes) 9 6 4

tCO2e 0 0 0

High temp recovery

(tonnes) 103 116 119

tCO2e 2 2 2

Non-burn disposal

(tonnes) 511 517 476

tCO2e 11 11 10

Landfill (tonnes) 19 43 54

tCO2e 5 10 13

Total waste (tonnes) 1,266 1,040 1,080

% Recycled or re-used 1.04% 0.72% 0.83%

Total waste tCO2e 31 31 35

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Governance - Directors’ report

The directors present their annual report together with the audited financial statements for Frimley Park Hospital NHS Foundation Trust (the Trust) for the period 1 April 2013 to 31 March 2014. The directors’ report incorporates the strategic report (including the Chairman’s and Chief Executive’s statements) by reference and together with the financial and activity review, gives an analysis of the development and performance of the Trust over the year and the vision for the future.

Board of directors

As can be seen from the directors’ biographies below and from our compliance with the requirements of the Monitor NHS Foundation Trust Code of Governance issued in December 2013, the Board of Directors (the Board) has an appropriate composition of skills and depth of experience to lead the Trust. The directors who held office during the year were:

Non-executive directors

Sir Michael Aaronson CBE Chairman Appointed to the Trust as Chairman of the Board and Council of Governors April 2006. End of tenure 31 March 2016. Chair of the Nominations Committee and Charitable Funds Committee Member of the Performance and Remuneration Committee

Mike’s earlier career was half in HM Diplomatic Service and half at Save the Children, where he was overseas director and subsequently, from 1995-2005, its Chief Executive. From 2001- 2008 he was Chairman of the Centre for Humanitarian Dialogue, a Geneva based private foundation working in conflict mediation, and from 2001-2007 a governor of the Westminster Foundation for Democracy. Since 2006 he has been a non-executive director of Oxford Policy Management Limited, a development consultancy providing policy advice in low and middle-income countries. At the end of March 2012 he stood down after five years as a civil service commissioner. He is an honorary fellow of Nuffield College, Oxford, and from 2008-2011 was a visiting professor in the politics department at the University of Surrey, where in May 2011 he became a professorial research fellow and executive director of the Centre for International Intervention. He has worked both with NATO and the UK Ministry of Defence on civil and military collaboration in conflict situations. In June 2006 Mike was knighted for services to children.

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David Clayton-Smith, BA Hons, CdipAF Independent non-executive director Appointed 1 April 2013. End of tenure 31 March 2016. Member of the Commercial Development and Investment Committee, Performance and Remuneration Committee and Nominations Committee

David is Chairman of the Kent, Surrey & Sussex Academic Health Sciences Network and was previously the Chair of NHS Surrey for three years from 2010. He was also the Chair of NHS Sussex between 2012 and 2013. David is a Board member and Treasurer of Fairtade International. David is director and co-founder of Andrum Consulting which specialises in supporting entrepreneurial businesses. David has held board level positions in major blue-chip businesses, most recently as Commercial Director of Halfords Ltd and Marketing Director for Boots the Chemist Ltd. This included a number of Merger and Acquisition (M&A) transactions such as the sale of Do It All Ltd to Focus Ltd and the sale of the Halfords garage business to Centrica Plc. David has held non-executive director roles in a number of different market sectors.

Stephen Crouch, MA Hons (Oxon), ACA Independent non-executive director Appointed 1 February 2013. End of tenure 31 March 2016. Member of the Audit Committee and Charitable Funds Committee

Stephen is currently Group Finance Director and Bursar at Wellington College Group. Stephen’s role encompasses Wellington College in Berkshire, a leading co-educational boarding school for 1,050 pupils, prep school Eagle House, a state secondary school – the Wellington Academy in Wiltshire, and Wellington College Tianjin in China. The group continues to grow with a further college opening in Shanghai in 2014 and more UK academies being planned. Before joining Wellington, Stephen was CFO and then Chief Executive of Steer Davies Gleave, a global employee owned economics consultancy working in public transport. Steer Davies Gleave had offices in the UK, Europe, Middle East and Americas, many of which Stephen was responsible for opening. Steer Davies Gleave was 18th in the Sunday Times ‘100 Best Companies To Work For’ and a Sunday Times Private Companies ‘Top 10 Ones To Recognise’ in 2009. Stephen previously worked in corporate finance and in restructuring for PricewaterhouseCoopers LLP and Ernst & Young LLP. Stephen has ten years M&A experience at director or board level in a variety of industries including consumer products and professional services in the UK, Europe, the Americas and Asia.

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Mark Escolme BA Hons Independent non-executive director. Deputy Chairman from 1 April 2013 Appointed 2009. End of tenure 31 March 2015. Chair of the Commercial Development and Investment Committee from 1 April 2011. Member of the Audit Committee

Mark has over 20 years of experience of working in large branded consumer companies in the UK, US, Australia and New Zealand. He has been involved in setting up businesses in emerging markets such as Russia, China, India and Africa, developing high profile brands within household and food categories. He has managed joint ventures and NGO and government partnerships. Working at board level, Mark chaired the SC Johnson East Africa board and currently sits as a non-executive director on the Standard Brands board. Mark is the managing director of GÜ. He is also a trustee for UK charity Gumboots Foundation, which raises money for social uplift initiatives in Southern Africa. Over the past 15 years Mark has had significant M&A experience in the UK and many international markets across multiple private, private equity-backed and public manufacturing businesses in executive and non-executive director roles. This includes Dow products (the Mr Muscle brand) in the UK and Bayer Pest Control (Baygon and Autan brands) in Africa.

Tina Oakley MA in Strategic Human Resource Management, CIPD Independent non-executive director Appointed April 2011. End of tenure 31 March 2017. Member of the Performance and Remuneration Committee and Nominations Committee Non-executive director representative on the Complaints Forum and the Clinical Governance Committee

Tina has over 30 years’ experience of working in customer service organisations, including 26 years in British Airways where she ran large customer operations including check-in and contact centres as well as holding a number of senior HR roles. She also had responsibility for worldwide customer relations handling. More recently Tina was HR Director at Rank Hovis McDougall when it was acquired by Premier Foods. Tina led the people integration and organisational design, policy and cultural change and remuneration alignment. Tina was also HR Director for P&O Ferries based in Dover where she led a number of significant change programmes. She is currently HR Director for Gatwick Airport, which is transforming every part of the business with the ambition to become London's airport of choice.

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Rob Pike ACIB Independent non-executive director Appointed April 2011. End of tenure 31 March 2017. Chair of the Audit Committee Non-executive director responsible for security and counter-fraud from 1 January 2013 Member of the Commercial Development and Investment Committee

Rob retired in 2009 after a 40 year career in financial services which culminated in a role as Director of Operations for Europe & Middle East for the Royal Bank of Scotland Group. He was previously Director of Operations in the UK where he had responsibility for more than 5,000 employees, running a network of operations at the time of the Royal Bank of Scotland acquisition of Natwest Bank. Rob was heavily involved in the subsequent integration of the two networks of operational banking centres, managing its major IT and transformation integration and was heavily involved in the post-acquisition HR and systems integration. Having successfully undertaken several senior customer facing roles he was invited to join the board of the Customer Contact Association (CCA) in 2004 and continues to serve as a director. He also chaired the CCA Industry Council from 2006-2008 and is currently Chair of the CCA Standards Council.

Andrew Prince BSc, FCMA Independent non-executive director, Senior Independent Director, Appointed 2006. End of tenure 31 March 2016. Chair of the Performance and Remuneration Committee Member of the Nominations Committee Member of the Charitable Funds Committee

Andrew is a specialist in large-scale organisational change, programme management and service integration in healthcare. As Development Director for Serco Health he is active within many parts of the NHS and in healthcare organisations overseas, particularly in Australia and the Middle East. He is responsible for the design of integrated non-clinical services for an advanced acute hospital in Perth, Western Australia, and for the Care Co-ordination solution now deployed at Suffolk Community Services in the UK. As Head of Strategy Consulting and Financial Services, Andrew led the HR strategy and merger of Arthur Young and Ernst & Whinney in 1990s. Andrew was elected as a governor of Frimley Park Hospital NHS Foundation Trust from April 2005 and retired as a governor on his successful appointment as a non-executive director of the Trust from April 2006.

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Executive directors

Andrew Morris, OBE, MHSM, Dip HSM Chief Executive Appointed 1989

Andrew has over 40 years of experience in NHS management and has held a range of senior NHS appointments. He became unit administrator of Hereford Hospitals and a board member of Herefordshire Health Authority in 1984. He was appointed General Manager of Frimley Park Hospital in 1989 and became Chief Executive in 1991. He managed the establishment of the Ministry of Defence Hospital Unit in 1996 and undertook one of the first successful NHS management franchise arrangements at Ashford and St Peter’s Hospitals NHS Trust in 2003, which lifted its performance from zero to two stars. He successfully led Frimley Park’s application to become a foundation trust in 2005. Andrew is a member of the Institute of Health Service Management. Andrew was named as one of the top 10 NHS provider chief executives in a panel convened by the Health Service Journal in March 2014.

Helen Coe MBE, MBA, RGN Acting Director of Operations Appointed 5 July 2013

The Director of Operations is a newly established position and is responsible for delivering quality services with excellent patient outcomes as well as ensuring that the Trust meets all the local and national operational targets. Helen has significant NHS expertise gained during her 30 years’ experience in a number of senior clinical and managerial roles. She has a strong operational background, has held several senior nursing positions across specialties in both Surgery and Medicine and has been awarded an MBE for her outstanding contribution to nursing and quality. Helen is passionate about ensuring patients receive the highest quality services and that their experience at Frimley Park Hospital is first class. Helen has also worked at the Department of Health as part of the Cabinet Office team assessing public organisations for the Charter Mark Award. Prior to taking up the position of Acting Director of Operations, Helen was the Associate Director for Urgent Care Services focusing on delivering the Trust’s hyperacute strategy in cardiology and stroke. She has been responsible for leading innovation and change and led the Trust’s successful transformation project reducing patients’ length of stay.

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Timothy Ho MB BS PhD DIC FRCP

Medical Director Appointed 2 December 2013

Tim graduated in medicine from St. George’s, University of London, and went on to undertake specialist training in respiratory and intensive care medicine in London. He carried out a period of basic science research in molecular microbiology at Imperial College, culminating in the award of a PhD. He has been a consultant chest physician at Frimley Park Hospital since 2004. During this time, he has developed a number of key services including a regional diagnostic service for lung cancer (EBUS), the medical acute dependency unit and a large obstructive sleep apnoea service. Most recently he has served as the clinical director for medicine and care of the elderly and as the centre director for the Frimley Park adult cystic fibrosis service. He is the professional lead for the doctors and is responsible for the Trust’s quality and clinical governance framework.

Janet King MA Law, FIPD, CPP Director of Human Resources and Facilities Appointed 1991

Starting her career in the civil service, Janet joined Frimley Park Hospital in 1987 working for West Surrey and North East Hants Health Authority as personnel manager. She became a director of Frimley Park Hospital NHS Trust in 1991. Her portfolio includes human resources management, all non-clinical support services, estate and capital planning, media and communications. She is project director for a number of large capital projects at Frimley and also chairs the Trust’s Fundraising Committee. Janet sits on a number of national committees and is a lay panel member for employment tribunals.

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Edward Palfrey OBE, MA, MB, Bchir, FRCS, FRCSEd Medical Director Appointed 2001. Retired from the Board 1 December 2013

Edward was educated at Christ College, Cambridge, and St Mary’s Hospital, London, and has been a consultant urologist at Frimley Park since 1990. Previously, he was a research fellow at St Thomas’, when he was responsible for running the first NHS lithotripsy (a kidney stone removal procedure) service. He played a key role in developing urology services at Frimley. Faced with ambitious targets and a testing financial agenda, Edward has led an on-going improvement in quality of services. This was recognised with Edward playing a significant role in Lord Darzi’s ‘Our NHS, Our Future’ review between September 2007 to February 2008 as the Chair of the Chairs and Clinical Lead for South East Coast Strategic Health Authority (SEC) and sitting on the SEC Quality Board. Edward is also a member of Monitor’s Medical Advisory Group. In 2009 he was awarded an OBE for services to healthcare.

Nicola Ranger RGN, BSc (Hons), MA Law & Medical Ethics Director of Nursing, Quality and Patient Services Appointed 2 January 2013

Nicola joined the Trust from University College London Hospitals where she was Deputy Chief Nurse. She specialised in intensive care nursing and spent four years working in critical care units in New York and Washington DC. Nicola has held a number of senior nursing positions including nurse consultant for critical care and head of nursing for both surgery and medicine. Her key areas of responsibility are professional lead for nursing, midwifery and therapies, maintaining clinical standards, patient safety, governance and patient involvement.

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Martin Sykes BSc, PhD, CPFA

Director of Finance and Deputy Chief Executive Appointed 2004

Martin has been Director of Finance at the Trust since July 2004 and Deputy Chief Executive since April 2007. He joined the NHS in 1995 with the Northern and Yorkshire Health Authority, having previously been employed by the University of Newcastle upon Tyne. Martin also has responsibility for contracting and information, procurement, and business development functions within the Trust and, as the Senior Information Risk Officer (SIRO), leads on information governance matters on behalf of the Board.

Changes to the Board

Non-executive directors

The Council of Governors (CoG) agreed during the year to extend the term in office of each of Sir Mike Aaronson, Chairman, and Andrew Prince, independent non-executive director, for a year from 31 March 2014 to 31 March 2015. Since the balance sheet date, the CoG approved an extension to the term of office of each of the Chairman and Andrew Prince up to one year to 31 March 2016, subject to the acquisition of Heatherwood and Wexham Park Hospitals NHS Foundation Trust proceeding.

Executive directors

Edward Palfrey, executive director, retired from the Board as medical Director on 1 December 2013.

Timothy Ho was appointed Medical Director on 2 December 2013.

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Governance – Corporate governance

Statement of compliance with the NHS Foundation Trust Code of Governance The Board of Directors considers that it was compliant with the provisions of the revised Monitor NHS Foundation Trust Code of Governance. Governance structure Frimley Park Hospital Foundation Trust (the Trust) is a public benefit corporation established under the Health and Social Care (Community Health Standards) Act 2003 (which was replaced by the National Health Service Act 2006).

The Board of directors (the Board) of the Trust attaches great importance to ensuring that the Trust operates to high ethical and compliance standards. In addition it seeks to observe the principles of good corporate governance set out in the Monitor NHS Foundation Trust Code of Governance published in December 2013.

The Board is responsible for the management of the Trust and for ensuring proper standards of corporate governance are maintained. The Board accounts for the performance of the Trust and consults on its future strategy with its members through the Council of Governors (CoG).

The CoG’s role is to influence the strategic direction of the Trust so that it takes account of the needs and views of the members, local community and key stakeholders, to hold the Board to account on the performance of the Trust, to help develop a representative, diverse and well-involved membership, and to help make a noticeable improvement to the patient experience. It also has to carry out other statutory and formal duties, including the appointment of the Chairman and non-executive directors of the Trust and the appointment of the external auditor.

Constitution

The Trust’s constitution was revised in February 2012 to reflect the importance of developing a strong working relationship between the Board and the CoG.

The number of formal public CoG meetings was changed from three to at least two meetings per annum, with at least four workshops being held in private between the governors and directors, so that the total number of meetings between the governors and directors will be at least six per annum.

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A number of changes were made to the constitution in the year 2013-2014 to incorporate statutory changes required under the Health and Social Care Act 2012, including the Approval of Significant Transactions. The constitution was approved by the CoG in May 2013 and by members at the Annual Members Meeting in September 2013.

The catchment area for membership of the Trust, which forms part of the constitution, will need to be re-drawn to reflect the enlarged catchment should the acquisition of Heatherwood and Wexham Park Hospitals NHS Foundation Trust (HWPH) (referred to in the Chairman’s statement) proceed. The current catchment map can be found on page 91.

The Trust continues to be open and transparent with the community through the public CoG meetings, the various health events held within the catchment area during the year, engagement with local interest groups and the large amount of information available on the Trust’s website.

The Trust’s corporate structure at 31 March 2014

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The Board

Directors

The biographies of the directors who held office during the year appear on pages 60 to 67.

Key roles and responsibilities

Chairman

The Chairman of the Trust is Sir Michael Aaronson, CBE, a non-executive director who has no conflicting relationships. His appointment is on the basis that he works two days per week for the Trust. Details of the Chairman’s other commitments are listed on page 60. The Board remains confident that he has sufficient time to devote to the Trust.

Deputy Chair

Mark Escolme served as Deputy Chair of the Board during the year under review and deputised for the Chairman at Board and other meetings (internally and externally) if he was unable to attend.

Senior Independent Director

The Senior Independent Director is Andrew Prince, who was elected to this position by the Board after consultation with the Lead Governor of the CoG and the governors serving on the CoG Non-Executive Director Performance and Remuneration Committee (NERC). Part of the role of the Senior Independent Director is to provide another route for communication with governors if they feel unable to raise a particular concern through the Chairman. The Senior Independent Director also undertakes the Chairman’s appraisal, after seeking feedback from the rest of the Board, the Company Secretary and from governors.

Company Secretary

The Board has direct access to the advice and services of the Company Secretary (Secretary), who is responsible for ensuring that the Board and Committee procedures are followed. The Secretary is also responsible for ensuring the timely delivery of information and reports. The Secretary is responsible for advising the Board, through the Chairman, on all corporate governance matters. The Company Secretary at the date of this report is Liz Taylor, who joined the Trust in July 2012. Liz Taylor has a 25 year career across a number of FTSE 250 public quoted companies in the retail, media and property sectors, most latterly as Company Secretary of the UK’s property portal, Rightmove plc.

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Operation of the Board

The Board meets regularly and has a formal schedule of matters specifically reserved for its decision. This includes high level matters relating to strategy, business plans and budgets, regulations and control, annual report and accounts, audit, and monitoring how the strategy is implemented at operational level. The Board delegates other matters to the executive directors and senior management.

Board meetings were opened to the public in April 2013. The Board met at nine scheduled meetings during the year under review plus two off-site informal strategy meetings. The Board also held four seminars on a variety of topics which provided the Board with more time to discuss topics of interest and importance to the Board. Regular contact, including with the non-executive directors, is maintained between formal meetings.

Board meetings follow a formal agenda, which includes strategy issues, financial and non-financial performance, clinical governance, operational performance and performance against quality indicators set by the Care Quality Commission (CQC), Monitor and by management. These include measures for infection control targets, patient access to the Trust and Emergency Department waiting times, length of stay, areas of quality for patients including the number of complaints, and the results of the Friends and Family Test.

The directors have timely access to all relevant management, financial and regulatory information. On being appointed to the Board, directors are fully briefed on their responsibilities.

Board training

Ongoing development and training requirements for individual directors are assessed annually through the appraisal process, with the Chairman leading on collective Board development, which is addressed at Board seminars and workshops. Formal training in the year included presentations from the Trust lawyers on the Health and Social Care Act 2012, including changes to the duties of directors and governors, and a report on the competition law aspects in relation to acquisitions.

Directors’ remuneration

Details of the directors’ remuneration, fees and expenses for the year and their service contracts and Letters of Appointment are set out in the Remuneration Report on pages 102 to 107. The accounting policies for pensions and other retirement benefits are set out in note 1.3 to the accounts.

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Appointment, re-election and the Nominations Committee

The directors are responsible for assessing the size, structure and skill requirements of the Board, and for considering any changes necessary or new appointments. If a need is identified, the Nominations Committee, which comprises the Chairman, two additional non-executive directors, and the Chief Executive and is assisted by the Director of Human Resources, will produce a job description, decide if external recruitment consultants are required to assist in the process and if so instruct the selected agency, shortlist and interview candidates. If the vacancy is for a non-executive director, the Nominations Committee is enlarged to include some of the governors serving on the NERC in the process. At the conclusion of the selection process, the NERC then recommends the selected candidate to the CoG for appointment.

Non-executive directors are appointed for a three-year term in office. A non-executive director can be re-elected for a second three-year term in office on an uncontested basis, subject to the recommendation of the Chairman on behalf of the Nominations Committee and the Board and the approval of the CoG. A non-executive director’s term in office can be extended beyond a second term on an annual case-by-case basis by the CoG, subject to a formal recommendation from the Chairman, satisfactory performance, and the needs of the Board, without the Trust having to go through open process. Removal of the Chairman or another non-executive director shall require the approval of three-quarters of the members of the CoG.

The Chairman, other non-executive directors, and the Chief Executive (except in the case of the appointment of a new chief executive) are responsible for deciding the appointment of executive directors. The Chairman and the other non-executive directors are responsible for the appointment and removal of the Chief Executive, whose appointment requires the approval of the CoG.

Directors and their independence At the end of the financial year, the Board comprised the Chairman, six executive directors and six non-executive directors. As at 31 March 2014, 31% of the Board members are female. The Board has reviewed and confirmed the independence of all the non-executive directors who served during the year, none of whom has any conflicting relationships. The composition of the Board is in accordance with the Trust’s constitution, which sets out the qualifications and reasons for the disqualification of the directors. The Board has concluded that the balance of executive to non-executive appointments is correct and appropriate.

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The Board also considers that the balance of skills and experience of its members is complete and appropriate to address the operational and economic challenges the Trust expects to face over the next few years. In light of the retirement from the Board of the Director of Transformation on 31 March 2013, the Board accepted the recommendation of the Nominations Committee to create the interim post of Acting Director of Operations with the aim of further strengthening the management team.

An induction programme was arranged for the two new non-executive directors who were appointed in February and April 2013, including a series of one-to-one meetings with the Chairman, the executive directors, and senior managers.

The executive directors hold no other Non-executive Directorships or commitments disclosable under the Monitor Code.

Performance evaluation and extensions to terms of office

During the year, the Performance and Remuneration Committee (PRC) and the Nominations Committee reviewed the composition of the Board and the performance of the individual directors. The term in office of the Chairman and the Senior Independent Director expired on 31 March 2014. Based on the recommendation of the Nominations Committee and with the support of the NERC, the CoG agreed to extend the term in office of each of the Chairman and Andrew Prince, who have served on the Board since 2006, for a further period of one year to 31 March 2015.

Subsequent events

Since the balance sheet date, the CoG approved an extension to the term of office of each of the Chairman and Andrew Prince up to one year to 31 March 2016, subject to the acquisition of Heatherwood and Wexham Park Hospitals NHS Foundation Trust proceeding.

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Board committees

The Board has the following committees, all being an essential part of the Trust’s governance framework:

Audit Committee

Performance and Remuneration Committee (PRC)

Nominations Committee

Commercial Development and Investment Committee (CDIC)

Membership of Board committees at 31 March 2014

1Appointed to the Board on 2 December 2013 2Retired from the Board on 1 December 2013

Director Position Audit Committee

Commercial Development & Investment Committee

Performance & Remuneration Committee


Non-Executive Directors

Michael Aaronson Chairman N/A N/A (Chair)David Clayton-Smith Non-exec N/A Stephen Crouch Non-exec N/A N/A N/A Mark Escolme Non-exec (Chair) N/A N/A Tina Oakley Non-exec N/A N/A Rob Pike Non-exec N/A N/A Andrew Prince Non-exec N/A N/A (Chair) Executive Directors Andrew Morris Chief Exec By invitation By invitation Helen Coe Interim Exec N/A N/A N/A Timothy Ho

1 Exec N/A N/A N/A N/A Janet King Exec N/A By invitation By invitationEdward Palfrey2 Exec N/A N/A N/A N/A Nicola Ranger Exec N/A N/A N/A N/A Martin Sykes Exec By invitation N/A N/A

Board of Directors

Audit Committee

Commercial Development & Investment committee

Performance & Remuneration Committee

Council of Governors


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The following table sets out the number of directors meetings held during the year and the number of Board committee meetings attended by each director:

Attendance record for the year ended 31 March 2014

Director Board

Audit Committee

Commercial Development & Investment Committee

Performance and Remuneration

Committee


Council of Governors and BoD/CoG Meetings

Total meetings 91 5 7 4 2 6

Non-Executive Directors

Michael Aaronson 9 N/A N/A 4 2 6

David Clayton-Smith 8 N/A 7 4 2 6

Stephen Crouch 7 4 N/A N/A N/A 5

Mark Escolme 5 3 6 N/A N/A 2

Tina Oakley 7 N/A N/A 4 2 3

Rob Pike 9 5 7 N/A N/A 4

Andrew Prince 9 N/A N/A 4 2 6

Executive Directors Andrew Morris 9 5 5 7 45 25 6

Helen Coe 2 6 of 6 N/A 1of 1 N/A N/A 4 of 4

Timothy Ho 3 3 of 4 N/A N/A N/A N/A 2 of 2

Janet King 8 N/A 5 2 525 4

Edward Palfrey 4 5 of 5 N/A N/A N/A N/A 1 of 4

Nicola Ranger 8 N/A N/A N/A N/A 5

Martin Sykes 8 5 5 6 N/A N/A 61 Board meetings in public 2 Appointed as Acting Director of Operations 1 July 2013 3 Appointed to the Board 2 December 2013 4 Retired from the Board 1 December 2013 5 Invited to attend the meeting

Register of directors’ interests

The register of directors’ interests is available for inspection during normal office hours at the Chief Executive’s office and is published on the Trust’s website.

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Audit Committee

Membership and attendance

The Chair of the Audit Committee is Rob Pike, non-executive director, who was appointed to the role on 31 December 2012. The Audit Committee comprises three independent Non-executive Directors. The Chief Executive and Director of Finance are normally invited to attend the meetings as well as the external and internal auditors. Other relevant managers from the Trust, including the Deputy Director of Nursing and Quality, are also invited to attend meetings in order to provide a deeper level of insight into certain key issues and development such as Risk and Quality.

Membership and attendance at meetings is set out in the table on page 74. The Board considers that Stephen Crouch, Non-executive Director, has recent and relevant financial skills and experience, as required by the Monitor Code of Governance.

In order to maintain independent channels of communication, the members of the Audit Committee meet in private twice a year with the internal and external auditors (both individually and collectively). This provides the internal and external auditors with an opportunity to raise any issues which may arise without the presence of management.

Role of the Audit Committee

The Audit Committee is responsible to the Board for reviewing the adequacy of the governance, risk management and internal control processes within the Trust. In carrying out this work the Audit Committee primarily utilises the work of internal audit and external audit. The Audit Committee also obtains assurance from the views of other external agencies about the Trust’s procedures, such as from the NHS Litigation Authority (NHSLA) and the Care Quality Commission.

The audit review of the financial year end annual report and accounts is discussed by the Audit Committee with the external auditor before the Board approves and signs the financial statements.

The Audit Committee ensures that there is an effective internal audit function established by management that meets mandatory NHS internal audit standards and it reviews the work and findings of the internal auditor. The Audit Committee agrees the schedule of internal audit reviews, receives the reports, and follows up on the issues raised. Managers from the areas reviewed are asked to attend the meeting and report on steps taken to avoid any problems arising again. The Audit Committee also follows up on any issues relating to process identified at the Clinical Governance Committee and Quality Committee.

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The Audit Committee receives and monitors the policies and procedures associated with countering fraud and corruption. An independent local counter fraud service provided by Baker Tilly (formerly RSM Tenon) produces a bi-monthly counter fraud progress report giving updates on both reactive and proactive work undertaken in the Trust.

Main activities of the Audit Committee during the year

The Audit Committee met on five occasions during the course of 2013-2014. At its meeting in May 2013 the Committee received the annual audit report from PricewaterhouseCoopers LLP (PwC) and recommended the annual accounts, the annual report, the quality report and the annual governance statement for 2012-2013 to the Board for final approval. Later in the year the Audit Committee also reviewed and recommended the Charitable Funds annual report and accounts 2012-2013 for approval to the Board.

During the course of the year the Audit committee received a number of audit reports from the internal auditors, TIAA. These ranged from financial control audits (accounts payable, accounts receivable, finance ledger and payroll), to IT audits and audits on aspects of patient care.

The Audit Committee considered a detailed internal audit report on progress with the Implementation of the Admission, Discharge and Transfers (ADT) bed management system (and IT system to track the availability of beds).

The Audit Committee received an internal audit report on the Innovation and Change Plan (a change management programme). In addition to reviewing the recommendations of the report the Audit Committee also sought assurances that the cost implications of the Plan had not had a detrimental impact on patient safety or quality of care.

From time to time, members of staff were invited to intend an Audit Committee meeting, for example the Patient Safety Facilitator was invited to a meeting in order to discuss the recommendations of the Patient Falls Management Review Audit Report.

Following the year end, the Audit Committee considered the draft Annual Report 2013-2014 and received the ISA 260 Report from PwC, which highlighted:-

The fact that the Trust’s estate had been re-valued by the District Valuer, leading to an increase in the value of the buildings to £9.3m;

A review of the accounting treatment for deferred income for the bowel cancer screening programme and maternity pathway;

The fact that the Trust had determined that the Trust’s charitable funds would not be consolidated on the grounds of materiality.

There were no significant issues to be reported for the year ended 31 March 2014.

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Trust auditors External auditor

PwC (Southampton) was appointed as the Trust’s external auditor for an initial term of five years from 1 April 2006 until the conclusion of the audit for the year ended 31 March 2011.

Following a competitive tender process, which was described in the 2010-2011 annual report, PwC was re-appointed by the CoG as the Trust’s external auditor for a further three-year term from 1 April 2011 until the conclusion of the audit for the year ended 31 March 2014. The CoG extended PwC’s appointment for a further two year term at the CoG meeting in September 2013.

Internal auditor

During the year under review, the Trust’s internal audit function has been carried out by Parkhill, who was appointed internal auditor with effect from 1 April 2012. Parkhill was established in the 1990s by combining a number of internal audit departments of various health providers and it is now a specialist provider of healthcare audit and assurance services. Parkhill merged with private sector firm TIAA Ltd on 1 October 2013 and is now called TIAA Ltd.

Auditor independence and non-audit services

At least once a year the Audit Committee reviews and monitors the external auditor’s independence and objectivity. The Audit Committee has a policy by which non-audit services and fees provided by the external auditor are approved. In addition to undertaking the external audit of the financial statements and assurance work on the quality report, the Trust engaged PwC to provide the following additional services during the financial year:

£ (excl VAT)

Analysis of the clinical and operational performance of Heatherwood & Wexham Park Hospitals NHS Foundation Trust 56,000

Preparation for the Care Quality Commission inspection 99,000

Training on application of Health Education Data (HED) system 53,000

PwC is also the external auditor of Frimley Park Hospital Charitable Funds, of which the Trust Board is the Corporate Trustee. The fees in respect of this engagement were £5k (excluding VAT).

The chair of the Audit Committee confirms the independence of the external auditors to the CoG at its meeting where the annual report and accounts are presented and also reports any exceptional issues to the governors during the course of the year.

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Disclosure of information to the auditor

The directors who held office at the date of the approval of the directors’ report confirm that, so far as they are aware, there is no relevant audit information of which PwC (the Trust’s external auditor) is not aware. They also confirm they each have taken all reasonable steps in order to make themselves aware of any relevant audit information and to establish that PwC knows about that information.



The Chair of the Nominations Committee is Mike Aaronson, Chairman of the Trust. The Nominations Committee comprises three additional independent Non-executive Directors. Membership and attendance at meetings is set out in the table on page 74.

Role of the Nominations Committee

A primary purpose of the Nominations Committee is to:

To liaise with the Board’s PRC to identify any missing skills on the Board;

To agree and recommend job descriptions and person specifications for Board vacancies;

To agree and recommend arrangements for the recruitment and selection of the executive directors;

To liaise with the Non-executive Director Remuneration Committee (NERC) concerning Chairman and Non-executive Director appointments and terms of office;

To agree any Appointments Panels for director vacancies.

Further information on the work of the Nominations Committee can be found on page 72 in the section describing Appointment and Recruitment.

Main activities of the Nominations Committee during the year

During the year the Nominations committee agreed the recruitment process for the role of Medical Director and Acting Director of Operations.

Performance and Remuneration Committee (PRC)

A description of the work of the PRC can be found on pages 100 to 102. Membership and attendance at meetings is set out in the table on page 74.

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Commercial Development and Investment Committee (CDIC)


The Chair of the CDIC is Mark Escolme, non-executive director. Membership of the CDIC comprises two additional independent Non-executive Directors, the Chief Executive, the Director of Finance, the Director of HR and Facilities, the Director of Operations and the Head of Business and Performance. Membership and attendance at meetings is set out in the table on page 74.

Role of the CDIC

Reporting to the Board, the CDIC has three main purposes:

To ensure that major capital investment schemes are in line with the Trust’s overall agreed strategy;

To offer the Board assurance on the rigour of the Innovation and Change Plan. and,

To review key commercial arrangements including long term leases, and major service developments. The CDIC will track the progress of such developments, as appropriate.

With regards to major capital investment schemes, the CDIC has a duty to ensure that a business case is prepared which includes sufficient information on the business needs, benefits, risks, funding and affordability, available options, costs, clinical and quality outcome measures, project development milestones, project management and regulatory requirements for it to decide whether or not to approve the scheme or lease. Main activities of the CDIC during the year The CDIC met on seven occasions during the course of 2013-2014. The CDIC approved a number of tender evaluations including the refurbishment of the Special Care Baby Unit (SCBU). The SCBU project was part of the Strategy 6000 (a programme designed to meet the projected 6,000 births per year in 2015-2016) which had been approved by the Board of Directors in 2012. At its meeting in July 2013 the CDIC received and approved an outline business case for additional bed capacity in preparation for pressures during the winter, when seasonal demand for bed spaces is at its peak. During the course of the design period for the new modular ward construction the original design specification was reconfigured to include spaces for a number of critical care beds, which would allow the hospital to care for more critically ill patients. Additional capital expenditure was approved for a new Interventional Radiology Suite and Fluoroscopy refurbishment project to provide enhanced diagnostic imaging in the Radiology Department.

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As part of its remit the CDIC also reviewed previous capital investments, measuring their success against the benefits criteria contained within the original business case to determine whether the project had delivered on the investment. Notably, the CDIC reviewed the benefits of the newly built Emergency Department (ED) and Day Surgery Unit (DSU). This had been the largest capital investment development ever undertaken by the Trust and had been delivered below the original budget. The CDIC was satisfied that the new ED had significantly increased capacity, further improved infection control compliance, and provided patients with much greater levels of privacy and dignity.

The CDIC sought assurances from managers that the metrics set out in the various work streams within the Innovation and Change Plan (a change management programme developed to deliver savings and meet tough efficiency targets) had been met. A series of work streams, which were aligned with the five themes of the Trust’s strategy, were reviewed including the Length of Stay (LOS) programme, staffing and organisational development.

Board, committee and directors’ performance appraisal

The directors recognise the importance of evaluating the performance and effectiveness of the Board as a whole, of the committees and of individual directors. The performance is assessed during the year in terms of:

Attendance at Board and committee meetings

The independence of individual directors

The ability of directors to make an effective contribution to the Board and committees through the range and diversity of skills and experience each director brings to the role

The Board’s ability to make strategic decisions and to lead the Trust effectively.

The Board and its committees have opted to conduct performance evaluation through questionnaires and discussion. In terms of individual appraisals, the Chairman undertakes the appraisal of the Chief Executive and the non-executive directors; the Chief Executive undertakes the appraisal of the other executive directors; and the Senior Independent Director undertakes the appraisal of the Chairman, having sought feedback from the rest of the Board, the Company Secretary and from the governors. The Chief Executive discusses and reviews the executive directors’ appraisals with the Chairman and the PRC.

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The process for the review of the Chairman and the non-executive directors has been approved by the NERC, which confirms the completion of the process to the CoG. Governors evaluate the performance of the Board as a whole in terms of meeting its targets and communicating with its staff, members and stakeholders. To assist the Trust in identifying any training needs, the governors also evaluate the performance of the CoG. The CoG retains the power to hold the Board of Directors to account for its performance in achieving the Trust’s objectives.

The results of the evaluation process of the Board’s performance in respect of the year to 31 March 2014 was that the Board collectively, and the directors individually, were deemed to have performed well. There remains a need to continue to focus on external engagement, and communication both internally as well as externally.

Evaluation of the committees also indicates that they are working well with a good level of debate and interaction between the non-executive directors and the executive directors and other employees who attend the committees. The Board will consider an external evaluation in future years.

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Governance - Directors' responsibilities statement and going concern

The directors are required under the National Health Service Act 2006 to prepare financial statements for each financial year. The Secretary of State, with the approval of the Treasury, directs that these financial statements give a true and fair view of the state of affairs of the NHS foundation trust and of the income and expenditure of the NHS foundation trust for that period. In preparing those financial statements, the directors are required to: apply on a consistent basis accounting policies laid down by the Secretary of State with the approval of the Treasury; make judgements and estimates which are reasonable and prudent; and state whether applicable accounting standards have been followed, subject to any material departures disclosed and explained in the financial statements.

The directors confirm to the best of their knowledge and belief that they have complied with the above requirements in preparing the financial statements.

The directors are required under the Monitor NHS Foundation Trust Code of Governance to consider whether or not it is appropriate to adopt the going concern basis in preparing the Trust’s financial statements (annual accounts). As part of its normal business practice, the Trust prepares annual financial plans. After making enquiries, the Board has reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. Accordingly, the Board continues to adopt a going concern basis in preparing the Annual Report and financial statements.


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Governance - Council of Governors and membership

Frimley Park Hospital NHS Foundation Trust (the Trust) has a Council of Governors (CoG). The Board of directors (the Board) reports to the CoG on the performance of the Trust and its progress against agreed objectives, and consults on its future direction. Governors report matters of concern raised at their local health event constituency meetings or other meetings to the CoG and directors. Members of the public have an opportunity to ask questions of the governors and any directors in attendance at the local health events or CoG meetings.

Membership comprises individuals in the following categories:

Within catchment: any resident over the age of 16.

Outside catchment: anyone over the age of 16 and who has been a patient or carer of a patient in the past five years.

Staff: any member of staff who has a permanent contract or has worked at the Trust for 12 months or worked on a series of short-term contracts amounting to more than 12 months.

Members are represented on the CoG by representatives from the public, patients and carers, staff and other stakeholder groups. More than half of the CoG is elected from the Trust’s membership, which means the 16,297 members (2013: 15,942) have a significant influence on the hospital’s future strategy. In this way, the Trust is directly accountable to its local community. The Trust is constantly exploring wider stakeholder engagement through its governors.

In February 2012, the CoG agreed to amend the Trust’s Constitution to reduce the number of formal public CoG meetings required to be held each year from three to two. The revised constitution states that the Trust will hold a minimum of two public CoG meetings each year, as well as at least four workshops in private between the governors and the Board, such that the total number of meetings between the governors and directors of the Trust will be not less than six per annum. In addition, governor drop-in sessions are hosted by the Chairman and the Chief Executive at which governors are able to raise concerns and questions. Many governors have attended the meetings of the Board since these were opened to the public on 1 April 2013.

Role of the governors

The CoG is responsible for the appointment of the Chairman and the non-executive directors, agreeing their terms and conditions, as well as the appointment of the external auditor. Each financial year, the CoG is consulted by the Board on the Trust’s forward plans and receives the Annual Accounts, Auditors’ Report, Annual Report and Quality Report. Governors respond as appropriate when consulted by the directors on specific issues. Governors are unpaid but they receive reimbursement of expenses.

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Lead governor

The publicly elected governors select one of their members to be the Lead Governor of the CoG. The Lead Governor would co-ordinate any communication that might in extreme circumstances be necessary between Monitor and the other governors and acts as a main point of contact for the Chairman and the Senior Independent Director. The Lead Governor at the date of this report is Nicola Dodsworth, Public Governor for Hart.

Governor expenses

Four governors claimed expenses in the year 2013-2014 (2012-2013: eight) which amounted to £150.20 (2012-2013: £523).

Register of governors’ interests

A register of governors’ interests is maintained. A copy of the latest version submitted to the CoG is available on the Trust’s website or it may be inspected during normal office hours at the Chief Executive’s office.

Composition of the CoG

The CoG comprises three main groups:

Public, patient and carer governors

At 31 March 2014, there are 21 public governors (2013: 19) who nominated themselves for election within their local constituencies, which are based on local authority boundaries. In addition two governors are elected to represent the patient and carer members who live outside of the Trust’s catchment area. The number of governors from each constituency reflects the number of hospital admissions in 2005, as detailed below:

Area Hospital admissions (%) Number

Rushmoor 30 6Surrey Heath 23 5Hart 20 4Waverley 12 2Bracknell Forest & Wokingham 8 1Guildford 7 1Patients and carers out-of-catchment1

(12% of total referrals)

2

1 The catchment area map on page 89 shows where the Trust draws 88% of patients. Patients and carers outside this area are classed

as ‘out-of-catchment’

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Staff governors

The four staff governors are elected by self-nomination and constituency voting and represent each hospital core directorate.

Governor representing Number

Medicine, Elderly Care, Pharmacy and ED 1

Surgery and Surgical Services 1

Women’s and Children’s Services and Diagnostics and Therapeutics 1

Administration / Management, Estates, Hotel Services and Parkside 1

Stakeholder governors

The Trust has a further eight governors who are appointed by partnership or stakeholder organisations (2013: 11).

Changes to the Council of Governors and elections 2013-2014

In accordance with its constitution, the Trust uses the method of single transferable voting for all elections. The single transferable voting system is designed to minimise wasted votes. It allocates an elector’s vote to his or her most preferred candidate and then, after candidates have either been elected or eliminated, transfers unused votes according to the voter’s next stated preference. An external electoral agent is appointed by the Trust to oversee the election process.

In the event that a governor resigns mid-term, the remaining governors can either invite the candidate who polled the next highest number of votes, if they received at least 10% of votes in the original election, to fill the vacant seat for the remaining period of office, or call an election. If the unexpired period of the term of office is less than nine months (or such other period as the CoG may from time to time determine by a majority vote), the seat may be left vacant until the next elections are held.

During the course of 2013-2014 there were two resignations on the CoG; the staff governor representing Medicine, Elderly Care, Pharmacy and ED resigned on 13 December 2013 and the Patient Carer/Outside Catchment governor resigned on 13 January 2014. The vacancies created by these resignations were advertised in the elections held in January 2014.

Stakeholder governors Number

Local authorities 2

County councils 2

Partnership organisations 4

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It was with great sadness that we reported that Nicholas Day, Public Governor for Surrey Heath, passed away on 31 October 2013. Nick was a dedicated and much respected Public Governor and a huge asset to the CoG and to Frimley Park Hospital more generally. Nick provided valued support to both fellow Governors and to members of the Board of Directors and his skills and expertise will be missed. The resulting vacancy in the Surrey Heath constituency, together with one other vacancy in the Guildford constituency, (which the CoG had approved to be held open at a meeting on 6 May 2013), were advertised in the elections held in January to March 2014.

The Trust held governor elections in January 2014 when 12 public, two patient/carer and two staff governor positions were up for election. There were uncontested elections in two constituencies: the staff constituency Medicine, Elderly Care, Pharmacy and Emergency Department and the Patient Carer/Outside Catchment constituency; however, in all the other constituencies in which there were vacancies contested elections took place. In total 38 candidates nominated themselves for 16 vacancies. Of those 16 vacancies, six governors stood for re-election, two governors did not stand for re-election, four governors were ineligible to stand for re-election having already served a maximum of nine years under the terms of the constitution (three terms of three years), two positions were vacant and had been held open until the election in January 2014 and two further positions had become vacant following recent resignations by a staff governor and a patient carer/outside catchment governor. On 1 April 2014, five governors were re-elected and 11 new governors elected to the CoG for a term of three years. Following the elections, there were no vacancies amongst the public, staff or patient carer governors on the CoG.

During the course of 2013-2014, there were a number of changes to composition of the Stakeholder Governors on the CoG. Surgeon Captain Rob Ross stood down as the MoD Stakeholder Governor on 31 August 2013 and was replaced by Surgeon Captain Fleur Marshall on 1 September 2013. Bill Chapman, Stakeholder Governor for the Local Authority Blackwater Valley Group of Councils resigned on 18 December 2013. A successor is being sought amongst the partnership Local Authorities. A full list of governors in post on 31 March 2014, and changes during the year, is set out on pages 88 to 90 with details of the number of CoG meetings attended by each governor. A full list of the new governors elected post the year end on 1 April 2014 is set out on page 90.

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Training

In addition to regular updates from the Board on the performance of the organisation, the CoG received two formal training sessions from the Trust lawyers on the changes to the Health & Social Care Act and constitution and the roles of directors and governors.

In addition the Trust held a joint training day with governors from the Royal Surrey County and Ashford & St Peters Hospitals where governors received presentations about performance, the health economy, and quality and income in the NHS. Governors also received presentations from Monitor and the CQC.

A similar joint event was held in April 2014 and included presentations from the Foundation Trust Network, GovernWell.

Understanding the views of governors and members

The Trust’s directors normally attend the CoG meetings to listen to the discussions on the topics being considered and questions raised by governors and members. Usually an executive and a non-executive director attend each of the local health event meetings. The Board also meets informally with the CoG at private workshops, which are used as development sessions and to encourage more interaction and feedback between directors and governors. The Chairman and Chief Executive host drop in sessions for governors in the months where there are no formal meetings or workshops scheduled.

Council of Governors for Frimley Park Hospital NHS Foundation Trust 1 April 2013 – 31 March 2014

Elected staff governors

Constituency name Full name Date of appointment

End of current tenure

Attendance1

Number of meetings 6

Staff: Admin, M’gement, Estates, Hotel Services, Parkside & others

Steve Rose 1 April 2013 31 March 2016 2

Staff: Women’s and Children’s & Diagnostic and Therapeutics

Elaine Edwards 1 April 2011 31 March 2014 Stood down

6

Staff: Medicine, Elderly Care, Pharmacy and ED

Paul Reilly 1 April 2011 31 March 2014 Resigned 13 December 2013

3 of 4

Staff: Surgery and Surgical Services

Jane Miles 1 April 2013 31 March 2016 6

1 Attendance at CoG meetings, comprising two public meetings and four workshops with Board members

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Elected public governors

Constituency name Full name Date of appointment

End of current tenure

Attendance1


Patient / Carer: outside catchment

Mary Sennett MBE 1 April 2005 31 March 2014 Stood down

2


Sam Beevor 1 April 2013 31 March 2014 Resigned 13 Jan 2014

3 of 4

Public: Bracknell Forest and Wokingham

Alison Jukes 1 April 2011 31 March 2014 Stood down

3

Public: Guildford Vacancy

Public: Hart Caroline Copley 1 April 2013 31 March 2016 4

Public: Hart Nicola Dodsworth 1 April 2007 31 March 2016 5

Public: Hart Denis Gotel 1 April 2005 31 March 2014 Stood down

6

Public: Hart Edward Sherwell 1 April 2008 31 March 2017 Re-elected

6

Public: Rushmoor Joan Gittins 1 April 2011 31 March 2017 Re-elected

6

Public: Rushmoor Colin Balchin 1 April 2005 31 March 2014 Stood Down

6

Public: Rushmoor Stuart Dodwell 1 April 2013 31 March 2016 2

Public: Rushmoor Patricia Crowley 1 April 2008 31 March 2017 Re-elected

5

Public: Rushmoor Harry Wood 1 April 2010 31 March 2016 6

Public: Rushmoor Ian Scott Wilder 1 April 2005 31 March 2014 Stood Down

6

Public: Surrey Heath Robert Bown 1 April 2011 31 March 2017 Re-elected

6

Public: Surrey Heath Keith Dingle 1 April 2011 31 March 2017 Re-elected

6

Public: Surrey Heath Anusha Everson 1 April 2013 31 March 2016 5

Public: Surrey Heath Carole Farrelly 1 April 2013 31 March 2016 5

Public: Surrey Heath Nicholas Day 1 April 2010 31 March 2016 Deceased 31 October 2013

3 of 3

Public: Waverley Michael Maher 1 April 2013 31 March 2016 5

Public: Waverley Susan Preston 1 April 2008 31 March 2014 Stood Down

5

1 Attendance at CoG meetings, comprising two public meetings and four workshops with Board members

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Appointed governors

Stakeholder organisation Full name Date of appointment / date of resignation

Attendance1


Adult Education Provider Wendy Finlay 1 April 2011 2

County Council: Hampshire John Wall 10 December 2009 6

County Council: Surrey Chris Pitt 3 October 2005 3

Local Council: Blackwater Valley Group of Councils

David Welch 1 April 2005 2

Local Council: Blackwater Valley Group of Councils

Bill Chapman 1 April 2005 Resigned 18 December 2013

3 of 4

Ministry of Defence Rob Ross

1 April 2013 Resigned 31 August 2013

1 of 2

Surrey Healthwatch – Frimley Hospital

Vacant

Stakeholder: Voluntary Services

John Evans 23 July 2012

6

Ministry of Defence Fleur Marshall 1 September 2013 4 of 4 1 Attendance at CoG meetings, comprising two public meetings and four workshops with Board members

New governors elected 1 April 2014

Constituency name Full name Date of appointment End of current tenure

Public: Hart Mel Williams 1 April 2014 31 March 2017

Public: Guildford John Ferns 1 April 2014 31 March 2017

Public: Bracknell Forest & Wokingham

John Lindsay 1 April 2014 31 March 2017

Public: Rushmoor Paul Turrell 1 April 2014 31 March 2017

Public: Rushmoor Michele White 1 April 2014 31 March 2017

Public: Surrey Heath Mary Probert 1 April 2014 31 March 2017

Public: Waverley John Pownall 1 April 2014 31 March 2017


Chris Waller 1 April 2014 31 March 2017


Rod McKeag 1 April 2014 31 March 2017

Staff: Medicine, Elderly Care, Pharmacy and ED

Udesh Naidoo 1 April 2014 31 March 2017

Staff: Women’s & Children’s and Diagnostics & Therapeutics

Karen Plews 1 April 2014 31 March 2017

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Engagement with governors and members Community Engagement Group (CEG)

The Community Engagement Group (CEG), formerly called the Stakeholder Engagement Group, is a sub-group of the CoG. It meets quarterly to co-ordinate actions on matters relating to Trust membership and stakeholder/community and public involvement and to provide feedback to the Board and the CoG.

The CEG receives presentations on membership activity, recruitment and retention, and local projects to foster engagement. This year the members of the group have considered presentations and discussions on the following areas:

Membership, including approval of the targets for 2014-2015

Governors and their constituency meetings

Community engagement, in particular with the Nepalese community

Fundraising

Results of the Governor elections

Corporate and Community Engagement (CACE) objectives for 2013-2016

The Trust’s use of social media

Patient Experience and Involvement Group (PEIG)

As a sub-group of the CoG, the PEIG meets quarterly to provide feedback to the Trust and the CoG on matters relating to service developments and patient experience. A description of the work of the PEIG can be found on page 37.

Membership catchment map for Frimley Park Hospital NHS Foundation Trust as at 31 March 2014

Members can contact governors or directors via: Foundation Trust Office Frimley Park Hospital Freepost G1/2587 Portsmouth Road Frimley Surrey GU16 5BR Tel: 01276 526500 Email: [email protected]

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Membership per local authority public constituency at 31 March 2014 (not including staff)

Constituency

1 Population per

constituency aged over 16*

Number of members

31 March 2014

Number of members

31 March 2013

% who are members

31 March 2014

Number of Governors

Members per Governor

31 March 2014

2 Election turnout

rates % by con-

stituency 2014

Rushmoor 75,424 2,988 2,970 4.03 6 498 18.1

Waverley 35,194 920 928 2.65 2 460 32.9

Hart 58,811 2,027 1,997 3.47 4 507 30.6

Guildford 21.998 551 558 2.55 1 551 27.8

Surrey Heath 66,726 2,942 2,906 4.45 5 588 23.0

Bracknell Forest & Wokingham

29,284 734 721 2.54 1 734 28.6

Out of Catchment

N/A 1,161 1,061 2 581 23.3

1 These figures use actual 2011 Census data with 2013 projections 2 Election rules - The Board confirms that all elections to the CoG are held in accordance with the election rules, as stated in the constitution.

Membership by staff directorate constituency at 31 March 2014

Directorate Number of members 31 March 2014

Number of members 31 March 2013

Women’s & Children’s Diagnostics and Therapeutics

1,243 1,208

Surgery and Surgical Services 1,087 1,059

Medicine, Elderly Care, Pharmacy and Emergency Dept

1,515 1,428

Admin, Management, Estates, Hotel Services, Parkside, others

1,129 1,056

Unspecified* 0 29*

Total 4,974 4,780

Major targets and actions to develop membership

The Trust’s aim over the period under review was to continue to find better ways of engaging with the membership, to educate and inform them, to seek their participation in events, obtain their feedback and capture their concerns. The following summarises the outcome of the annual targets for membership for 2013-2014.

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Membership numbers

The aim was to stabilise membership numbers to 15,000 by 31 March 2014. This was achieved and the Trust ended the year with 16,297 members. (2012-2013: 15,942).

Public / out-of-catchment members

The annual target was to ensure at least 10,500 of the total membership came from public and out-of-catchment constituencies. This was achieved with 11,323 members from these constituencies. (2012-2013: 11,141).

Staff

At 31 March 2014 the Trust had 4,974 staff members. The Trust continued to improve links between staff governors and staff members, publicising the names of staff governors to staff in prominent staff areas, involving staff governors more as observers in the Chief Executive briefings, and seeking their advice on corporate documents. (2011-2012: 4,780).

Maintaining 2.5% of constituency populations as members

The Trust achieved representation of 2.5% in all constituencies of the catchment area. The constituencies on average have 3.3% representation. Recruitment events again have taken place in all constituencies with the membership manager, governors and volunteers attending. Individual constituency representation is as follows: Guildford 2.6%, Bracknell Forest & Wokingham 2.5%, Waverley 2.7%, Hart 3.5%, Rushmoor 4.0% and Surrey Heath 4.5%.

Socio-economic groupings

The Trust aimed to focus on the diversity of membership and to increase contact with members in under-represented socio-economic groups to obtain their views on the hospital. The Trust continued to focus on increasing membership from hard-to-reach, seldom heard groups by holding recruitment events in venues that these people are known to visit. These included garden centres, DIY stores and computer shops, recreation centres and swimming pools. This activity will continue in 2014-2015. The socio-economic analysis indicates the Trust membership has a good distribution of social class groupings. This distribution will continue to be taken into account in on-going membership recruitment.

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Public membership* breakdown by socio-economic group at 31 March 2014

Socio-economic group

Eligible households*

Number of public members 31 March 2014**

Number of public members 31 March 2013**

ABC1 69,125 6,661 6,587

C2 19,742 1,858 1,613

DE 14,919 1,590 1,902

Not assigned 0 0

Total 10,109 10,102

* These figures use 2011 Census data with 2013 projections. 2011 census data only counts households by socio economic

group, not individuals. **Excludes Out-of-Catchment members

Age / gender

The Trust has more female members than male. The Trust continued and will need to continue to target men aged 20 to 59, who are under-represented, by holding events at venues they were likely to frequent, such as fitness centres and golf clubs. As at 31 March 2014 the male to female members’ ratio was 36.9 to 63.1 (31 March 2013: 37.6: 62.4)

Public membership breakdown by gender at 31 March 2014

Catchment Membership 2014 Membership 2013

Male 49.8% 36.7% (3,734) 37.5% (3,786)

Female 50.2% 62.7% (6,376) 62.1%(6,273)

Unspecified 0.5% (52) 0.4% (42)

In the year from 1 April 2013 to 31 March 2014, following a data cleanse, 973 members were removed from the database, of whom 363 were male.

Public and patient membership breakdown by age profile at 31 March 2014

Age (years) Public number of members

Patient number of members

Eligible membership catchment 1

% of catchment population

0-16 30 7 4,151 0.9

17 - 21 1,102 196 20,149 5.6%

22+ 8,755 958 263,260 3.3%

Unspecified 275 1 estimate based on 2011 census data and closest age band

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Ethnicity

The Trust continues to need to increase BME (black minority ethnic) membership from local communities whose ethnic mix has changed as a result of recent settlements. The analysis of the catchment area for ethnicity provided by the membership database provider (MES) uses the 2011 census data with 2013 projections. The total number of BME Trust public members (inside catchment) has increased to 772 in March 2014 from 681 in March 2013. However taking into account 151 removals from this group due to a data cleanse, true recruitment was 242. 479 members chose not to state their ethnicity.

Public membership breakdown by ethnicity at 31 March 2014

Ethnicity % composition of catchment population

Public membership (as % in brackets) March 2014

Public membership (as % in brackets) March 2013

White 90.72 8,911 (87.7%) 8,958 (88.7%)

Mixed 1.78 100 (1.0%) 95 (0.9%)

Asian 5.83 518 (5.1%) 398 (3.9%)

Black 1.14 121 (1.2%) 113 (1.1%)

Other 0.53 33 (0.3%) 75 (0.7%)

Not specified 479 (4.7%) 462 (4.6%)

Total 10,162 10,101

Annual major health events

The careers event ‘A Taste of Frimley Park’ for younger people took place in November 2013. It was again a huge success with very positive feedback from the 96 students who attended. Many of these students are actively considering a career in health service. The event will take place again in November 2014.

Constituency meetings (local health events)

Local constituency meetings enable direct consultation and debate by governors with the members on topical issues. The Trust continued to develop governor constituency meetings to give attendees more opportunity to take part.

Two of the meetings in 2013-2014 were ‘constituency meetings-plus’, longer events running from 6pm to 10pm with extra exhibits for the public to learn more about health and engage with staff. Feedback was very positive so the Trust held another such event in April 2014.

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Attendances remained higher than ever for the local health events with an average audience for the eight meetings of 144 people. The best attended was the Rushmoor constituency plus meeting in September 2013, with more than 250 people. The meetings were also well publicised. For example:

o Posters were put up in targeted doctors surgeries, libraries and shops in all constituencies by governors and in the hospital

o Constituency meeting details were advertised in Foundation Trust Newsletters o Meetings were advertised on the Trust’s website and main entrance information

touch screens o Local media were informed as appropriate and events were publicised on social

media via the Trust’s Facebook and Twitter accounts

Public attendance at constituency meetings (local Health Events) 2013-2014

Constituency Date Members attended

Guest speaker

Hart (Constituency meeting-plus)

30 April 2013 220 Dr Mark Norman (cardiology)

Bracknell Forest and Wokingham

28 May 2013 90 Dr Otilllia Speirs (stroke)

Waverley 25 June 2013 130 Miss Valerie Nunez (hand surgery)

Guildford 9 July 2013 70 Mr Gareth Beynon (obstetrics and gynaecology)

Rushmoor (Constituency meeting-plus)

17 September 2013 250+ Dr Tim Ho (respiratory)

Surrey Heath

15 October 2013 100 Miss Isabella Karat (breast cancer)

Hart 12 November 2013

110 Dr Beata LeBon

Bracknell Forest and Wokingham

14 January 2014 90 Mr Mark Gudgeon (colorectal surgery)

Waverley 4 February 2014

150 Dr Otillia Speirs (stroke)

Guildford 4 March 2014 90 Miss Valerie Nunez (hand surgery)

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Handheld devices for interactive feedback

The Trust continued using the 200 handheld electronic ‘KEEpad’ devices at all local health events. These give audiences a better way to interact with speakers and all public responses to specific questions collected electronically at the meetings are collated as feedback to the CEG and the PEIG.

Membership engagement and mechanisms for reviewing membership plans

Improving membership involvement continued to feature as a topic for discussion with the governors’ CEG. The CEG monitors delivery of membership activity.

Membership recruitment events were held at many locations, including: Aldershot Centre for Health, colleges in Farnborough, Farnham and Camberley, garden centres, sports centres, large stores and at the workplaces of several big local employers.

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Governance – Remuneration report Information not subject to audit Remuneration of Executive Board 2013-2014

The narrative elements of the Remuneration Report are not subject to audit. The salary and pension information on pages 103 to 106 has been audited along with details on the median salary as a ratio of the highest paid director’s remuneration on page 107. The Remuneration Report includes details of the remuneration paid to the Chairman and directors of the Trust (the ‘senior managers’ who influence the decisions of the Trust as a whole).

There are two committees within the Trust’s governance arrangements with responsibility for remuneration of the Board of directors.

Non-Executive Directors Performance and Remuneration Committee (NERC)

Role of the NERC

This committee of the Council of Governors (CoG) reviews the performance and remuneration of the Chairman and non-executive directors and makes recommendations to the full Council.


The Chair of the NERC is the Lead Governor, Nicky Dodsworth. The agreed membership of the NERC is:

Lead Governor of the CoG (chair of this committee)

At least five other members elected from the publicly elected governors

One member from among the staff governors

One member from among the stakeholder governors

Company secretary in attendance

The membership and attendance at NERC meetings is set out in the table on page 99.

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Membership of the NERC and attendance at meetings during 2013-2014

Name Position Attendances

Total meetings held 3

Nick Day Public Governor 2 of 21

Nicola Dodsworth Lead Governor of CoG, Public Governor

3

Anusha Everson Public Governor 3

Denis Gotel Public Governor 3

Alison Jukes Public Governor 1

Michael Maher Public Governor 2

Paul Reilly Staff Governor 2 of 2 2

Steve Rose Staff Governor None

John Wall Stakeholder Governor 2

Ian Wilder Public Governor 2

Sir Michael Aaronson Chairman Attendance by invitation as appropriate

Andrew Morris Chief Executive Attendance by invitation as appropriate

Janet King Director of Human Resources and Facilities

Attendance by invitation as appropriate

Andrew Prince Senior Independent Director Attendance by invitation as appropriate

1Deceased 31 October 2013. 2 Retired from the CoG 13 December 2013

The NERC reviews the fees paid to the Chairman and non-executive directors, taking into account the Trust’s performance, the fees paid by other foundation trust hospitals, the economic environment and any national guidance relating to senior managers and other staff in the NHS. The fees paid to the Chairman and the non-executive directors were unchanged in 2011-2012 and 2012-2013 in line with the Government’s restriction on pay increases for senior managers and consultants in the NHS. With effect from 1 April 2013, the fees were increased by 1% in line with the NHS pay award.

The fees paid to the Chairman of the Trust for the year ended 31 March 2014 were £52,397 (2012-2013: £51,878). The fees paid to each of the non-executive directors in the year ended 31 March 2014 were £13,762 (2012-2013: £13,625).

Annual performance appraisals of the non-executive directors are undertaken by the Chairman, with the senior independent director undertaking the appraisal of the Chairman, all based on the roles of the individuals on the Board and the strategic objectives of the Board. In the case of the Chairman’s appraisal, the views of the governors are also taken into consideration, with the Lead Governor liaising with fellow governors and providing feedback to the Senior Independent Director.

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The NERC received confirmation from the Chairman that the appraisals of the non-executive directors had been completed and from the Senior Independent Director that the appraisal of the Chairman had been conducted. There were no performance issues which needed to be addressed.

The Trust’s constitution states that the CoG can remove the Chairman or a non-executive director provided that the resolution to remove the individual has the approval of three-quarters of the members of the CoG.

Performance and Remuneration Committee (PRC) Membership and attendance

The Chair of the PRC is Andrew Prince, Senior Independent Director. The PRC comprises three additional independent non-executive directors, including the Trust Chairman. The Chief Executive is normally invited to attend the meetings except those at which his salary and terms and conditions are being discussed. The Director of Human Resources and Facilities attends the PRC by invitation in an advisory capacity. The Company Secretary attends the meeting and takes the minutes. The PRC met on four occasions during the course of 2013-2014. The details of the members of the PRC and their attendance at meetings are set out on page 74.

Role of the PRC

The PRC of the Board sets the remuneration for the Chief Executive and executive directors.

The PRC has responsibility for setting the terms and conditions of individual executive directors who all have open-ended service contracts of employment. Termination periods are set by the PRC and will range from six to 12 months’ notice for new appointments. Termination payments are considered on a case-by-case basis in line with guidance issued by the Department of Health. Contracts are in accordance with best practice and employment law. The PRC has agreed that the executive directors’ remuneration be benchmarked to the market every other year. The PRC may make small adjustments in the interim year, taking account of the rate of inflation. During the year the PRC has focused on growing a performance culture by adopting external best practice; this has included redesigning appraisal processes to reflect the desired behaviours associated with the Trust’s new organisational values.

In line with the Government’s restriction on pay increases for senior managers and consultants in the NHS, salaries for the executive directors remained unchanged for the year 1 April 2012 to 31 March 2013.

101

An external market review of the remuneration of the executive directors was undertaken by the Hay Group on behalf of the Trust in January 2013. Following this review, and having regard to the pay increase to NHS employees, and that executive directors had had a pay freeze since 2009, the base pay for executive directors was increased by 1% with effect from 1 April 2013.

Bonuses are based on performance levels attained and are made as part of the appraisal process. Bonuses relate to performance in the year in which they become payable to the individual. The bonuses reported in the remuneration tables for 2013-2014 relate to performance in 2012-2013.

Full details of the salaries, bonuses and pension entitlements of the directors of the Trust are detailed on the next two pages. The information in the following tables has been audited.

Details of the Trust’s staff costs are set out in note 4 of the Trust’s accounts. Main activities of the PRC during the year

At its meetings in April and June 2013, the PRC received a summary of the appraisals of the executive directors from the Chief Executive. It also received the recommendations for the base salary and bonus payments to be made to each executive director for their performance against their individual objectives for 2012-2013. The PRC also reviewed the Board and executive director objectives for 2013-2014 and agreed the rules of a bonus scheme for the executive directors based upon the individual and team targets. In January 2014 the PRC reviewed the annual salary survey conducted by the FTN.

Subsequent events (after the balance sheet date)

Remuneration advisers

The Chairman and Chief Executive engaged the services of the Hay Group on behalf of the Trust to assist with the Board and Organisation Design of the enlarged Trust (relating to the proposed acquisition of Heatherwood & Wexham Park Hospitals NHS Foundation Trust). The report was presented to the PRC at its meeting in April 2014, when through the Chairman and the Chief Executive, the PRC reviewed the proposed Board structure. At the time of the preparation of this report, the work continues. The fees will be reported in the financial year 2014-2015.

Remuneration 2014-2015

The PRC agreed a base 1% pay award for executive directors at its meeting on 3 April 2014.

102

Off-payroll engagements The table below shows the number of highly paid and/or senior off-payroll engagements as at 31 March 2014 where the payment is more than £220 per day and where the arrangements have been in existence for more than six months.

Number of existing arrangements 31 March 2014

No in existence for less than one year 1

No in existence one-two years nil

No in existence two-three years 2

No in existence three-four years nil

No in existence four or more years 1

There are no other off-payroll arrangements required to be reported under Annex 8 of Chapter 7 of the Monitor Annual Reporting Manual. Governor expenses

Four governors claimed expenses in the year 2013-2014 (2012-2013: eight) which amounted to £150.20 (2012-2013: £523).

Info

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subj

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to a

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It is

not

cas

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mun

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dditi

on to

the

abov

e, P

aula

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d, w

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ft th

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ch 2

013,

was

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m o

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in A

pril

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rel

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g to

an

expe

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103

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ntit

lem

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of s

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anag

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2012

-201

3 N

ame

Titl

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& fe

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(ban

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104

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Median salary / highest paid director

The HM Treasury Financial Reporting Manual 2011-2012 (FReM) introduced the requirement to disclose the median remuneration of all staff employed by the reporting entity and the ratio between this figure and the mid-point of the banded remuneration of the highest paid director. The calculation is based on full time equivalent staff of the reporting entity at the reporting period end date on an annualised basis.

The following data represents the ratio of median annual salary to the highest paid director’s remuneration.

31 March 2014 31 March 2013

Highest paid director’s remuneration £197,500 £217,500

Median salary:

Annualised WTE basis £24,048 £23,439

Represented as a ratio 8.2 9.3Explanatory note for above:

The median pay calculation is based on the payments made to staff in post on 31 March 2014.

The reported salary used to estimate the median pay is the gross cost to the Trust, less employer’s pension and employer’s Social Security costs.

The reported annual salary for each whole time equivalent has been estimated by multiplying the March 2014 payment by 12 months.

Payments made in March 2014 to staff who were part-time were pro-rated to a whole time equivalent salary.

The estimated annual salary is based on the payments made in March 2014. Therefore, it was necessary to remove ‘non-recurrent’ items paid within the March payroll. This was undertaken as a manual exercise on an individual staff member basis. There were no adjustments made for holiday pay or national holidays.

Included in the calculation is an estimated average cost for agency staff. All agency staff expenditure is processed through dedicated account codes on the financial system. The total March 2014 expenditure on these codes also includes an estimate of whole time equivalents based on equivalent NHS staff. To estimate the whole time equivalent an adjustment is made to allow for agency staff premium and fees. An annual salary was allocated to the agency whole time equivalent based on the average annualised salary for the equivalent NHS staff and included in the median calculation.

The highest paid director is excluded from the median pay calculation.

The highest paid director’s remuneration is based on their total remuneration which includes all salaries and allowances (including fees), bonus payments and other remuneration.

The salary of the highest paid director has been taken as the midpoint of their £5,000 total remuneration banding.

The Trust performs all of its services in house with the exception of laundry. This may contribute to a higher ratio than in other organisations where significant support services are outsourced and therefore the median salary may be higher.

Andrew Morris Andrew Prince Chief Executive Chair, Performance and

Remuneration Committee 22 May 2014 22 May 2014

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Statement of the Accounting Officer

Statement of the Chief Executive's responsibilities as the Accounting Officer of Frimley Park Hospital NHS Foundation Trust

The National Health Service Act 2006 states that the Chief Executive is the Accounting Officer of an 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 the independent regulator of NHS foundation trusts (Monitor).

Under the NHS Act 2006, Monitor has directed Frimley Park Hospital 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 Frimley Park Hospital 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 judgments 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 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.


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Annual Governance Statement 2013 - 2014 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 to provide services of a high quality. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. The Trust’s Standing Orders and Scheme of Delegated Authority outline the accountability arrangements and scope of responsibility of the Board, executive directors and the organisation’s officers. The Board has been fully involved in agreeing the strategic priorities of the Trust, with the most important priorities being those set out in the Trust’s Annual Plan and Board objectives, against which the Board submits regular reports to the Council of Governors. The Board receives regular minutes and reports from each of the nominated committees that report into it. The terms of reference of the committees of the Board have been reviewed to ensure that governance arrangements continue to be fit for purpose. All executive directors report to me and the performance of the executive team is held to account through team and individual objectives. The Trust’s Corporate Assurance Framework has been in place all year. In line with national guidance it is structured around the high level risks that were deemed to be the most significant risks in delivering the corporate objectives as set out in the Trust Annual Plan. The Corporate Assurance Framework is reviewed on a monthly basis by the corporate governance group, which is an executive group chaired by the Chief Executive, and by the Board. 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 Frimley Park Hospital NHS Foundation Trust.

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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 Frimley Park Hospital NHS Foundation Trust throughout the year ended 31 March 2014, and up to the date of approval of the annual report and accounts. Capacity to handle risk Key officers and responsibilities Directors All executive directors, clinical directors, and associate directors and heads of service of the Trust have a key role to play in developing a strong risk management approach in all aspects of the Trust’s activities, both clinical and non-clinical. Business priorities and decisions made by the Hospital Executive Board and Board of Directors must reflect risk management assessments and consideration of high risk factors. Non–executive directors The Audit Committee is chaired by a nominated non-executive director. All non-executive directors have a responsibility to challenge robustly the effective management of risk and to seek reasonable assurance of adequate control. Director of Finance The Director of Finance oversees the adoption and operation of the Trust’s Standing Financial Instructions including the rules relating to budgetary control, procurement, banking, staff appointments, losses and controls over income and expenditure transactions, and is the lead for counter fraud. The Director of Finance is the chair of the Information Governance Committee and Senior Information Risk Owner (SIRO) at Board level. The Director of Finance attends the Trust’s Audit Committee but is not a member, and liaises with internal and external audit, who undertake programmes of audit with a risk based approach.

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Director of Nursing, Quality and Patient Services The Director of Nursing is the executive lead with responsibility for the development, management and implementation of the Trust’s Corporate Assurance and Quality Frameworks and is accountable for ensuring there is a robust system in place for monitoring compliance with standards and the Care Quality Commission (CQC) Registration legal requirements. The Director of Nursing is responsible for managing patients’ risk, complaints, patient information and medical negligence claims and, with the input of the Medical Director, setting the quality standards. Medical Director The Medical Director is responsible for clinical governance, quality improvement, speciality dashboards, and the Trust Morbidity & Mortality process. He is responsible for the development of clinical quality standards within the Trust and, in conjunction with the Director of Nursing, ensuring effective integrated clinical governance is developed and monitored. The Medical Director is the Caldicott Guardian. The Medical Director has delegated responsibility as the nominated Responsible Officer for the Trust to a senior clinician, whose role is to evaluate doctors’ fitness to practise, based on supporting information presented to him, including through the appraisal process; the Responsible Officer will make recommendations to the General Medical Council on the revalidation of doctors (normally at five-yearly intervals). Both the Medical and Nursing Directors are responsible for ensuring that cost improvement plans are risk assessed and will not impact on the quality of care. Director of Human Resources and Facilities The Director of Human Resources and Facilities has overall responsibility for workforce planning, ensuring the right staff are in the right jobs, and for the management of the Occupational Health and Safety Department. The Director of Human Resources and Facilities ensures that the estate is developed to support Trust strategic direction and that the condition of the estate is maintained and is fit for purpose and that hotel services are effective and efficient. The Director of Human Resources and Facilities is the co-executive lead for the local implementation of the Climate Change Act 2008 and the development and implementation of the Trust’s Carbon Reduction Strategy. The Director of Human Resources and Facilities develops the Trust’s public and staff engagement strategy.

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Director of Operations The Director of Operations is responsible for the day-to-day management of the Trust. The role co-ordinates plans and strategies to ensure that the organisation develops services in an efficient and economical manner in response to the changing economic climate. The Director of Operations is the lead for delivering the Innovation & Change programmes which transform services within the Trust and Health Economy. The role involves ensuring that the Trust meets national and local performance objectives. Deputy Director of Nursing & Quality The role of the Deputy director of Nursing & Quality is to promote risk management activity awareness and training throughout the Trust. The post holder is directly accountable to the Director of Nursing, with a key function of providing central support and advice to the Board regarding the establishment of an effective system of internal control and developing the Corporate Assurance Framework. The Risk Manager has an overarching responsibility for ensuring there is an effective incident reporting process and effective management of all risk data and information, producing the Trust’s risk register and providing reports and trend analysis information to support the prioritisation of risk, as well as ensuring risk registers are maintained within directorates. The Risk Manager ensures that all serious risk incidents are reported to the Board of Directors, Foundation Trust regulator Monitor, the CQC and the Clinical Commissioning Groups, and are managed in line with the Serious Incident Policy. Embedding and managing risk at all levels of the organisation The Trust’s Risk Management Strategy, endorsed by the Board, is reviewed annually and sets out the organisation’s approach to risk management and future objectives. Appendix 1 sets out the key risk management functions and internal control responsibilities of the Board and committees that relate to it. All executive and clinical directors and associate directors and heads of service have a responsibility to lead with a strong risk management approach in all aspects of the Trust’s activities. Business priorities and decisions made by the Hospital Executive Board and Board of Directors reflect risk management assessments and consideration of high risk factors.

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Managers at all levels of the organisation have a responsibility to manage risks at a local level and to develop an environment where staff are encouraged to identify and report risk issues proactively. Each directorate maintains a risk register and key risks are assessed and reflected in the Corporate Risk Register, which is reviewed monthly for consideration by the Board of Directors. Managers are expected to ensure that their staff report immediately any near miss incidents, adverse incidents and serious incidents, using the Trust’s incident reporting procedure to provide appropriate feedback regarding specific incidents reported, and implementing recommendations following investigations to reduce the likelihood of the incident happening again. All members of staff have an important role to play in identifying and minimising risks and hazards as part of their everyday work within the Trust. Each individual has a responsibility for their own personal safety and for the safety of their colleagues, patients and all visitors to the Trust. All staff are expected to have an understanding of the incident reporting procedure and knowledge of the corporate categories of incident, which must be reported. A Trust-wide training needs analysis for risk management and patient safety has been undertaken and a range of training programmes have been integrated into the Corporate Training Plan. All staff receive mandatory annual updates in risk management and patient safety and attendance is monitored through the quarterly training statistics. The Trust’s Risk Management Strategy clearly defines the levels of authority for the management of identified levels of risk and describes the Trust’s interpretation and definition of ‘acceptable risk’. The risk and control framework The Risk Management Strategy sets out the framework and systems for implementation of risk and governance in the Trust. These processes are evidenced within the CQC Essential Standards of Quality and Safety. The strategy includes the following key elements:

It describes what is meant by ‘risk management’

It identifies the roles and responsibilities of all staff within the Trust

It clearly describes the roles and responsibilities of the key accountable officers

It sets out the process of risk management as follows:

i. Annual risk assessments and Trust risk grading matrix ii. Incident reporting procedure and root cause analysis

iii. Management of Trust’s Risk Register

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iv. Levels of authority for the management of identified risks v. Definition of ‘acceptable risk’

vi. Corporate Assurance Framework vii. Risk management training and education

viii. National standards and external assessments ix. Compliance with legislation

Quality is embedded in the Trust’s overall strategy. The Trust’s Quality Report includes national and local priorities with measurable quality improvement targets and deadlines. Quality targets are linked to directorates and included in local clinical speciality dashboards and pathway compliance monitoring. The Trust’s performance against the quality priorities is included in the Trustwide Quality and Performance report which is reviewed on a monthly basis by various committees and ultimately by the Board.

The Trust’s self-assessment against Monitor’s Quality Governance Framework has been reviewed by the Corporate Governance Group and by the Board and has demonstrated overall compliance with the requirements of the lines of enquiry. The Corporate and Local Risk Registers are reviewed monthly at the Trust Corporate Governance Group, Hospital Executive Board and Associate Directors/Heads of Service meetings. The minutes of the Corporate Governance Group outlining these discussions are presented to the Board of Directors on a monthly basis together with the full Risk Register. All risks identified have clear actions to reduce or mitigate them and this information is presented and shared with the Board.

The key financial and non-financial risks faced by the Trust moving forward include:

Acquisition of Heatherwood & Wexham Park Hospital and the potential of failure to achieve the work required within timeframes whilst maintaining performance at FPH

Risk of failure to deliver the Informatics Strategy as a key part of the quality & efficiency objective

Risk to financial stability through transformation/savings plan not being achieved & costs therefore exceeding plan

Risk of potential poor patient experience through the delivery of a patient transport service that does not fully meet the requirements

Involvement of public stakeholders

The Trust serves a dispersed community, which straddles the boundaries of three counties and two local health authorities. It also works with local authorities and Clinical Commissioning Groups. Given these complexities, there is a strong desire to work closely with the local community to provide coherent and effective services.

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The Trust provides information and assurance to the public on its performance against its principal risks and objectives in a number of different ways including:

The organisation has been a Foundation Trust since 1 April 2005 and has established a patient and public involvement framework which reflects current guidance. There are approximately 16,297 members (as at 31 March 2014) who are represented by a Council of Governors involving staff and public members.

The Council of Governors receives regular updates on the status of the Board objectives and uses this, along with the ratings by Monitor and the CQC, to hold the Board to account for its performance. Also, the Council of Governors is invited to input to the Annual Plan for Monitor.

In addition to the formal meetings of the Council of Governors, joint workshops are held with the Board when there is an opportunity to discuss and challenge performance and the priorities for the organisation. The workshops include reference to the key risks the Trust faces and an explanation as to how they are being managed.

Regular constituency meetings are held with members of the public and key stakeholders and attended by members of the Board of Directors. Consultation with the public is undertaken in developing new services and where key changes are proposed to existing services which may impact upon them.

Compliance with CQC The Trust received one inspection from the CQC during 2013-2014, in November 2013, as part of the CQC new programme of inspections when the Trust was found to be compliant with the essential outcomes. The Foundation Trust is fully compliant with the registration requirements of the CQC. Compliance with equality, diversity and human rights legislation 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 assessments are required for all new Trust business cases and all policy development and review, including those related to employment.

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Compliance with NHS Pension Scheme regulations As an employer with staff entitled to membership of the NHS Pension Scheme, the Trust has control measures 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. Compliance with climate change adaptation reporting to meet the requirements under the Climate Change Act 2008 The 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. Compliance with Information Governance and Data Security The Trust delivers annual information governance training for all staff raising awareness amongst them of the importance of protecting patient information. The training also encourages staff to report personal data related incidents. All reported incidents are investigated by the Trust’s Information Governance team and where applicable Trust policies and procedures are revised to prevent incidents re-occurring. This enables lessons learnt to be incorporated into the Trust’s Information Governance training.

The Trust has a network of IG Champions and Information Asset Owners (IAO) who work together to implement the Trust’s Annual Information Governance Work Programme ensuring the security and management of the Trust's information assets. The Trust score in the Information Governance Toolkit was 75% at the end of March 2014. A comprehensive work programme has been developed to increase the Trust’s Information Governance Toolkit score in 2014-2015.

The Trust reported no serious untoward incidents in 2013-2014 involving personal data as at March 2014. A summary of data-related incidents reported during the year is shown below:

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Data related incidents 2013-2014 Review of economy, efficiency and effectiveness of the use of resources The Trust ensures economy, efficiency and effectiveness through a variety of means, including:

A robust pay and non-pay budgetary control system

A suite of effective and consistently applied financial controls

Effective tendering procedures

Robust establishment controls

Continuous service and cost improvement and modernisation The Trust benchmarks efficiency in a variety of ways, including through the national reference costs index and by comparison with the annual surpluses generated by all foundation trusts. The Trust is consistently benchmarked in the upper quartile. The Board of Directors performs an integral role in maintaining the system of internal control supported by the Audit Committee, internal and external audit, and other key bodies. Annual Quality Report

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

A Corruption or inability to recover electronic data 0 B Disclosed in Error 24 C Lost in Transit 1 D Lost or stolen hardware 0 E Lost or stolen paperwork 0 F Non-secure Disposal – hardware 0 G Non-secure Disposal – paperwork 0 H Uploaded to website in error 0 I Technical security failing (including hacking) 0 J Unauthorised access/disclosure 2 K Other 9 Total 36

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The Annual Quality Report 2013-2014 has been developed in line with relevant national guidance and is supported internally through the Board Assurance Framework. As in previous years the report sets out the priorities for the coming year and it includes patient safety, patient experience and clinical effectiveness indicators. The data owner for each indicator submits the required data to the quality team following an agreed timeframe. The data validity is the responsibility of the data owner and on an ‘as required basis’ the quality team will undertake a review of the data provided as well as challenge data that appears inconsistent. The Trust has a Hospital Executive Board which is attended by all Executive Directors. All data and information within the Quality Report is reviewed through this committee and is supported through the three year Quality Improvement Strategy. The Hospital Executive Board and the Board of Directors review performance against the quality indicators on a monthly basis. This is monitored through the Quality Performance Dashboard and the Hospital Executive Board receives progress updates against any improvement projects. The Quality Report has been reviewed through both internal and external audit processes and comments have been provided by local stakeholders including commissioners, patient representatives, and the local authority.

Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit, and the executive managers and clinical leads within the NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the Quality Report attached to this Annual Report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the results of my review of the effectiveness of the system of internal control by the Board, the Audit Committee and the Corporate Governance Group and a plan to address weaknesses and ensure continuous improvement of the system is in place. The Corporate Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed.

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My review is also informed by:

The Trust’s assurance process for monitoring levels of compliance against CQC registration

CQC Inspection November 2013

Dr Foster NHS Hospital Trust of the year for South of England

National NHS Leadership Board/Governing Body of the Year 2014

NHSLA Risk Management Standards - achieved level 3 compliance in October 2012

CNST maternity services - achieved level 3 compliance in February 2012

Clinical Pathology Accreditation (CPA)

Picker National Patient Survey and patient feedback questionnaires

Annual Staff Survey

Environmental health inspection

Programme of work undertaken by internal and external audit and Audit Committee

MHRA GCP Inspection

Deanery and college inspections

The work of the Clinical Audit and Effectiveness Committee

NPSA national reporting and learning system incident report, September 2013 and March 2014

Responses from Monitor to the quarterly Board declaration process In assessing and managing risk, the Board and related committees have a substantial role to play in reviewing the effectiveness of the system of internal control, as follows:

Board of Directors

Through the review and approval of the Trust Risk Register, Corporate Assurance Framework, and key performance indicators, and approval of the Trust’s Governance / Risk Management Strategy and commitment to the action plan for implementing the strategy.

Audit Committee

Through the risk based programme of internal audit. Corporate Governance Group

Through the review and management of the Trust’s Risk Register and the key performance indicators for risk management, and the development of the Trust’s Governance/Risk Management Strategy.

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Clinical Governance Committee

Through the specialty clinical risk assessments and approval of the Trust-wide clinical risk assessment and directorate presentations under the CQC Standards of Quality and Safety framework. The Clinical Governance Committee, which is attended by executive directors and one non-executive director and up to one governor, reviews the clinical governance framework of the Trust and provides assurance to the Board through the Medical Director that the policies and practices recommended by the CQC and others are being followed. Quality Committee

Through the monitoring and review of the quality of services provided by the Trust including the review of internal core and speciality dashboards, morbidity and mortality reviews and external quality improvement targets. A more detailed description of the risk management functions and internal control responsibilities of the Board and related Committees are set out in Appendix 1. Overall control Substantial assurance has been given by the Head of Internal Audit that there is a generally sound system of control designed to meet the organisation’s objectives and that controls have been generally applied consistently throughout 2013-2014. Conclusion There were no control issues of major consequence in 2013-2014.


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Appendix 1 The following sets out the roles of the key committees with responsibility for managing and reviewing the process and effectiveness of the systems of internal control within the Trust. Board of Directors Set and monitor progress to the achievement of the Trust’s objectives, both strategic and operational Identify the significant risks that may threaten the achievement of the Trust’s objectives Identify and evaluate the key controls in place to manage the significant risks identified in the

Corporate Assurance Framework Identify positive assurances and areas where there are gaps in controls and assurances Put in place plans to take corrective action where gaps have been identified in relation to significant

risks Maintain dynamic risk management arrangements including, crucially, a well-founded Risk Register and

Corporate Assurance Framework, reviewed quarterly by the Board Commercial Development and Investment Committee Consider controls on business cases and significant investments Assess and evaluate benefits realisation Audit Committee Review the adequacy of the processes supporting all risk and control related disclosure statements (in

particular the Statement on Internal Control), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances

Review the adequacy of the underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks, and the appropriateness of the above disclosure statements

Review the policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements

Set the policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by the Counter Fraud and Security Management Service

Corporate Governance Group Assess, prioritise, and monitor the Trust’s performance in managing risk and ensuring progressive

improvement against the Trust’s ‘live’ Corporate Risk Register Prioritise the top risks to inform the Audit Committee and for review by the Board Ensure the Trust has a Corporate Assurance Framework that is robust and fit for purpose and complies

with best practice Review the Corporate Assurance Framework identifying any gaps in assurance, to inform the Audit

Committee and for review by the Board Compile, in conjunction with the Chief Executive, the Annual Governance Statement which will be

passed to the Audit Committee to review its adequacy Advise the Trust in respect of the development and use of key performance and risk indicators Support the Audit Committee by undertaking risk based work programmes where gaps in assurance

are identified. Respond to findings of the Audit Committee, ensuring action is taken

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Quality Committee Ensure the Trust is providing a high quality service Be responsive to significant patient safety risks Oversee, monitor, and review the quality of services provided by the Trust. This will include review of: Corporate/Governance and Directorate Level, risk management and internal control systems to

ensure that the Trust’s services deliver safe, high quality, patient-centred care Performance against internal core and specialty dashboards and external quality improvement

targets: o Clinical outcomes o Patient safety o Patient experience

Key quality and patient safety risks identified from reviewing mortality data and undertaking mortality and morbidity review at both speciality and Trust level

Progress in implementing action plans to address shortcomings in the quality of services, should they be identified

Advise the Board on the priorities for clinical standards set by National bodies e.g., Department of health, CQC and National Institute of Clinical Effectiveness

Provide assurance to the Board of Directors that the most efficient and effective systems are in place and the associated assurance processes are optimal

Be responsible for setting, monitoring and reviewing, on behalf of the Board of Directors, the quality improvement targets set in the quality account. Monitor National guidance (e.g. NICE guidance, NCEPOD, CEMACH) ensuring compliance

Clinical Governance Committee

Set, agree, and review strategic direction for the Clinical Governance Framework Set and agree a Clinical Governance reporting schedule, agree action programmes for sub committees,

and assess directorate clinical risk registers Agree and monitor performance of individual directorate clinical governance action plans with

particular reference to directorate risk registers and assess compliance with the CQC Standards of Quality and Safety

Receive reports from the relevant sub committees and recommend actions Harmonise corporate and directorate clinical audit programmes Hospital Executive Board Review financial and contractual performance on a monthly basis Discuss and agree recommendations relating to policy and strategy Ensure that the hospital is patient-focused and has improving patient experience at the heart of all it

does With advice from the Clinical Governance Committee, ensure that the hospital has sound clinical

governance and risk management arrangements, complies with key quality standards and undertakes a quarterly review of the Corporate Risk Register

Health, Safety and Environment Committee Ensure compliance with Health and Safety Executive legislation Address occupational health and safety risk issues Monitor non-clinical incidents Respond to Health and Safety Executive inspections and reports

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Information Governance Committee Ensure compliance with Data Protection Act 1998 and Freedom of Information Act 2000 Address and reduce information governance risks/issues Monitor all reported data losses and implement policies, procedures, and technical solutions to reduce

data losses across the Trust


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125 (1)

QUALITY REPORT 2013 - 2014

2

3

Contents

What is a Quality Report? Introduction

Part 1: Chairman and Chief Executive Statement

Statement on quality from the Chairman and the Chief Executive

Part 2: Priorities for improvement and Statement of Assurance

2.1 Priorities for improvement 2014-2015 2.2 Statements of assurance from the Board 2.3 Reporting against core indicators 2013-2014

Part 3: Other Information

3.1 Quality overview – Trust quality performance in 2013-2014 3.2 Frimley Park Hospital NHS Foundation Trust performance against selected Monitor metrics

2013-2014

Annexes

i. Statements from the Council of Governors, commissioners and Overview and Scrutiny Committees (OSC)/Healthwatch

ii. Statement of Directors’ responsibilities iii. Glossary iv. External audit data quality standards v. Limited Assurance Report

vi. CQC Pre inspection (2013) indicator dashboards.

4

What is a Quality Report?

Since 2010, all NHS foundation trusts have been required to publish an annual report on the quality of services they provide. The content is set by the National Health Service (Quality Report) Regulations 2012 and Monitor’s Detailed requirements for quality reports 2013-2014.

This report is set out as follows:

Part 1: Statement on quality from the Chairman and the Chief Executive 2013-2014. Part 2: The priorities for improvement for Frimley Park Hospital NHS Foundation Trust (the Trust)

over the next 12 months (2014-2015), and statement of assurance from the Board. Part 3: The Trust’s performance against last year’s quality improvement priorities and ambitions.

Introduction

Frimley Park Hospital NHS Foundation Trust (the Trust) is a nationally recognised, leading foundation trust serving a population in excess of 400,000 across north-east Hampshire, west Surrey and east Berkshire. The Trust provides planned, emergency and hyper acute stroke, cardiology, trauma and vascular services, ensuring patients receive first class, lifesaving care.

The Trust is in the first year (2013-2014) of a new three year Quality Strategy, developed in accordance with the direction identified by Lord Darzi and the three categories that define quality:

Patient Experience

Clinical Effectiveness

Patient Safety

Patient experience We aim to improve patient experience when they leave hospital by improving the discharge planning process and the quality of patient information. We will aim to ensure that we deliver first class care by staff who continually demonstrate kindness, compassion, professionalism and skill, together with an ambition to do even better for our patients, families and carers. We believe that care should be delivered in partnership and we will work to ensure communication is effective at all stages of our patients’ journey.

Aim: Reduce avoidable harm by a

further 15%

Aim: Improve discharge

planning and patient

information Aim: Maintain mortality index

in upper quartile

Patient safety We will work to ensure there will be no preventable harm to patients from the care they receive from us by fully embracing Don Berwick’s report A promise to learn – a commitment to act, and the ambitions defined in the Keogh Mortality Review.

Clinical effectiveness The most appropriate care and treatment will be provided at the right time, in the right place by the right staff.

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Part 1 Statement on quality from the Chairman and the Chief Executive

2013-2014 proved to be another busy year. The Trust saw an unprecedented rise in Emergency Department (ED) activity: medical emergencies increased by 4% and surgical emergencies increased by 6% over 2012-2013. We also saw 399,000 patients in our outpatient departments and were delighted to share in the celebration of the birth of 5,318 babies. The small reduction in the number of births this year compared with 2012-2013, (5,564) is reflective of the fall in the national birth rate.

Despite the busiest year the Trust has ever seen, we continued to push the boundaries of quality for our patients. During 2013-2014, we celebrated some significant achievements:

1. In December 2013, the Trust was awarded Trust of the Year (South of England) by the Dr Foster Hospital Guide for mortality and safety, just one year after being named Hospital of the Year national runner-up. Dr Foster Intelligence [producers of the guide] are recognised as one of the most important independent assessors of quality and safety in NHS hospitals. Mortality rates are a principal focus for Dr Foster in assessing patient safety in hospitals. Mortality and safety ratings continue to be within the top five of hospitals trusts in England.

Tim Baker, chief executive officer of Dr Foster Intelligence, visited the Trust in January to present the award to hospital staff. It was accepted on behalf of all staff by a cross section of colleagues.

Tim Baker said: "It gives me great pleasure to present this award to everyone at Frimley Park. Delivering great hospital care is a huge team effort by both clinical and non-clinical teams and everyone at the hospital is responsible for

getting this award. I think the staff should be very proud. It is particularly satisfying, from our perspective, to see clinician led services in action seven days a week. We don't necessarily choose when we are ill so it is really good to see the positive impact that it has on the care delivered and outcomes for patients."

2. The Trust received an overwhelmingly positive report following the most rigorous inspection the Trust has ever undergone by the Care Quality Commission (CQC) and maintained our unconditional registration for all services. The Trust was selected as one of 18 trusts to undergo the new comprehensive inspection regime as an example of a ‘low risk’ organisation. See annex VI CQC pre-inspection (2013) indicator dashboards.

3. Awarded Board/Governing Body of the Year at the National NHS Leadership Recognition Awards 2014. The awards sought to recognise staff who go the extra mile to motivate and inspire their peers, and provide exemplary patient care.

4. Sustained very high levels of patient satisfaction. Once again we are very proud to say that over 99% of our patients’ rate their care as good, very good or excellent and 99% would ‘probably’ or ‘definitely’ recommend us to their friends and family (Trust’s own patient satisfaction survey).

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Patients who responded to the national Adult Inpatients Survey 2013 conducted by the Picker Institute praised levels of privacy, the quality of food, and access to information following treatment. Results placed the Trust in line with our counterparts, scoring upwards of 80% across eight of the ten core assessment areas. Patients said the Trust excelled, in particular, in ensuring waiting times were kept to a minimum and that admission dates were adhered to. Those using the ED said they were satisfied with the information available on their condition/treatment and stated that there was adequate privacy throughout the department.

5. Achieved performance in the upper quartile for the national Friends and Family Test (FFT). The FFT was introduced in April 2013 for inpatients and patients who attended the Accident and Emergency department. The Trust is very grateful to all those patients who took the time to give us their feedback and this has enabled us to achieve such an outstanding response rate of 37% for inpatients and 24% for the Accident & Emergency department compared with a national target of 20%. The Trust can therefore have greater confidence in the excellent net promoter scores achieved when compared with Trusts who have lower response rates. See section three for detailed results.

In October 2013 the Trust introduced the FFT for women using maternity services, in line with the national programme. The first six months’ results are excellent with 99% of our patients telling us that they would be ‘extremely likely’ or ‘likely’ to recommend our maternity services to their friends and family. See part three for full results.

6. Made significant progress towards reducing patient harm by a further 15% by the year 2015-2016 after successfully reducing harm rates by 53% in the period 2009-2013. During 2013-2014 we further reduced harm to our patients by an average of 20%. See page 21 for full results. Although we have seen an increase in the number of methicillin-resistant staphylococcus aureus (MRSA) bacteraemias from one last year to four this year, only one of these was reported to be avoidable.

7. In 2013-2014 we also made significant progress in improving quality for our staff. We were delighted to receive confirmation from both the Care Quality Commission and the national Staff survey, that our staff are ‘overwhelmingly’ happy working for the Trust and are passionate about caring for our patients, their families and carers.

8. A key focus during 2013-2014 has been refreshing our Leadership development strategy and enhancing our Tools for change programme.

9. Ward leadership programme. 22 senior sisters embarked on a clinical leadership programme over nine months, finishing in the summer of 2014. The key focus of the programme was liberation and empowerment to enable the ward sisters to take ownership of their clinical area with the quality focus of improving safety, experience, performance and outcomes for patients.

10. The Trust achieved the Investors in People Bronze award in 2013 in recognition of the excellent and comprehensive communication, induction and training systems in place. Bronze status is only awarded to the top 5% of Investors in People organisations.

11. Four apprenticeship programmes have been implemented for Healthcare Assistants, two at level two and two at level three. A total of 30 staff are due to complete their apprenticeship during 2014 and 2015. The apprenticeship includes functional skills for English and Maths, plus BTEC and Diploma in Health Care. The programmes are designed to equip care assistants with the necessary training and knowledge to deliver safe care and improve the quality of care delivered.

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12. Implementation of the Customer Service Strategy which articulates the Trust’s values [committed to excellence, working together and facing the future]. The success of the strategy has been evidenced by the results of a local question added to the national staff survey. A remarkable 92% of staff said that they understood the new values. Additionally, almost 100% of managers and over 1,400 front-line staff have received customer service training over the last 12 months.

13. The Trust has also taken a proactive approach to help staff manage stress within the work environment and improve their own health and well-being by:

Holding two health days in the last year, each attended by over 400 staff. The drop-in sessions included body ‘MOTs’, cholesterol testing and smoking cessation support, as well as taster sessions in a variety of complementary therapies.

Introducing a roaming health kiosk for staff to have their blood pressure, weight and body mass index (BMI) checked.

Facilitating fitness sessions such as a weekly Pilates classes and an on-site subsidised staff gym. Membership now exceeds 350.

In November 2013, the Trust hosted a team of CQC assessors as the Trust participated in the new style, extensive inspection regime. The Trust was selected by the CQC as an example of a ‘low risk’ hospital, and was one of 18 trusts selected for this first wave of inspections.

In December 2013, the Trust received an excellent inspection report from the Chief Inspector of Hospitals, Professor Sir Mike Richards. The Trust was recognised as having a passion for excellence, dedicated staff and a high standard of service. The report went on to say that staff working at the Trust are ‘overwhelmingly happy’ and described them as ‘a workforce of dedicated staff caring for people’.

The Trust is extremely pleased and reassured that the conclusions the inspectors reached in this report were overwhelmingly positive and it is heart-warming and reassuring to see that the CQC recognised so much good practice and dedication from our excellent staff.

Inspectors spent two days on site and spoke with more than 80 patients and over 100 staff. As part of the inspection the CQC held a public listening event to hear the opinions and experiences of patients and the public.

The CQC report picked out several areas as examples of best practice, including:

Warm and sensitive interactions between staff and patients. Great teamwork and leadership in A&E. An open culture of learning. Good end of life care. Excellent education and support for junior doctors. Highly visible and outstanding leadership.

There were no actions that the Trust must take to improve.

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The Trust is pleased that the inspectors recognised the support and training our junior doctors receive. Ensuring junior doctors receive the best experience at the Trust helps us recruit and retain excellent doctors now and into the future. It is gratifying that Health Education Kent, Surrey and Sussex positioned us as the top hospital trust for junior doctors in 2013.

The CQC recommended the Trust continue the work already commenced regarding: implementing existing plans for dementia patients, reviewing ‘Do Not Attempt Resuscitation’ (DNAR) procedures, and enhancing infection control protocols in the mortuary.

Prior to the inspection, the Trust had developed plans to improve further the care for patients with dementia and to improve the environment to ensure admissions are less stressful for patients, their families, and carers. DNAR and the mortuary protocols have already been fully addressed.

As recognised by Dr Foster, over the past several years the Trust has been at the forefront nationally of developing seven day working. The Trust will continue to enhance and extend consultant delivered services, seven days a week. For example, the Trust currently employs 14 consultants in the ED. At least one consultant is present between 8am to midnight, seven days a week leading the team and ensuring patients receive the highest possible standards of care.

The Trust continues to strengthen hyper-acute services and has launched the Surrey Heart, Stroke, and Vascular Centre (2013-2014), providing cardiovascular services to patients in Hampshire, Surrey, and Berkshire. The new centre brings together a number of specialties at the hospital to improve patient outcomes. The service was developed following recent guidance on best practice from the Department of Health. Conditions treated at the centre will include coronary heart disease, vascular disease, stroke and related conditions such as diabetes, kidney disease, hypertension and cholesterol management. Clinicians in the Cardiac Catheter Laboratory are now undertaking around 1000 percutaneous coronary interventions (PCI) procedures and 2500 angiograms on an annual basis. Furthermore clinicians are undertaking more complex procedures, with 2013 seeing the first embolisation performed at the Trust.

We are delighted that our smallest patients and their parents can enjoy first class surroundings and care in our new local Neonatal Unit (NNU). The NNU began welcoming patients in December 2013 and was officially opened by the Countess of Wessex in March 2014. The Countess was kind enough to express her thanks to the staff who looked after her and said: "The service you provide is paramount and can literally make the difference between life and death, I can attest to that. It is rare to have the opportunity to thank people for the huge difference they have made at an important time in your life so I am so pleased to be here and to be able to say thank you in person.” The Countess graciously spent time meeting new mothers and their babies as well as clinicians, neo-natal nurses, and pediatricians. The unit has 16 neonatal cots, eight designated for special care and eight for high dependency/intensive care. At a time when parents and families are understandably anxious, this new facility will provide them with the best possible environment and high standards of care provided by the team.

Quality Performance in 2013-2014

During 2012-2013 the Trust articulated the desire to be recognised, locally and nationally, as the leader in quality healthcare, delivering safe, clinically effective services, focused entirely on the needs of the patient, their relatives and carers. During 2013-2014 the Trust has made significant progress towards achieving that ambition.

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Patient Safety

We have seen significant improvements in a number of patient safety priorities as a result of the focused efforts of all our staff.

Priority Baseline data 2012-2013 2013-2014 Trend over

Time*

Methicillin-Resistant Staphylococcus Aureus bacteraemia (MRSA)

4 (2008-2009)

1 1 (avoidable) 3 (unavoidable)

Clostridium difficile (C.diff) (The year end position for the indicator above has been audited by PwC)

85 (2008-2009)

16 15

Pressure Ulcers Grade 2 Grade 3 Grade 4

269 52 15

(2008-2009)

144 15 0

88 (Feb) 7 (Feb)

0

% falls with significant harm by overall activity.

0.10% (2010-2011)

0.03% 0.03%

Venous Thromboembolism (VTE) % risk assessment (higher better)

83% (2010-2011)

93% 97%

Safety Thermometer** Average Harm Free Care (higher better)

93% (2012-2013)

93% 95%

Source: Trust performance data and NHS Safety Thermometer March 2014. *Trend over time relates to the performance against baseline data – the first full year of data collection for each indicator shown in brackets.

Thumbs horizontal – performance maintained. Thumbs up – performance improved. Thumbs down – performance worsened. ** Safety Thermometer, national tool used to measure harm from falls, pressure ulcers, VTE and catheter associated urine tract infections.

We are extremely proud that our rate of infection is among the lowest in the country. Cases of MRSA are apportioned to the Trust if the blood culture specimen date is on, or after, the third day of admission even if the infection has been contracted in the community. Each MRSA case is subject to a thorough clinical review to identify where the infection was contracted and whether there were any actions we could have taken in order to prevent infection. Only one MRSA case was assessed as avoidable. The root cause was agreed to be PVL MRSA (a community strain) that was present at, but not detected during admission screening. There were learning points identified related to urinary catheter care. 50 members of staff (of all grades) have been educated as a result of a post infection review of this case.

Monitor (the Trust’s regulator) regard any hospital’s performance as good where there are fewer than 6 cases of MRSA in a year.

Clostridium difficile (C.diff) cases are apportioned to the Trust if the stool specimen date is on, or after, the fourth day of admission. There were 15 Trust apportioned cases during 2013-2014. A thorough root cause analysis of each case found no link in time, place or team, and that the cases were different ribotypes. This means that there was no evidence of cross-infection. Additionally, the clinical indications are that most of the infections are due to antibiotics given in accordance with the current antibiotic policy. As a result the Trust’s microbiologists have recommended that all guidelines be reviewed with particular focus on the antibiotic choice used in pneumonia, urinary tract infections, sepsis and intra-abdominal infections to promote the use of antibiotics less likely to cause C.diff.

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It is important to say that C.diff is sometimes difficult to avoid when a patient’s condition means they require antibiotic treatment. The Trust will therefore work to ensure that the most appropriate antibiotic is prescribed both in hospital and by GPs in the community. Work is already underway with our commissioners and our community colleagues. We have also taken action to review our antibiotic usage policy to ensure that our patients are cared for using the most up to date guidelines and evidence based medicine.

The number of Trust cases for 2013-2014 is similar to that reported in 2012-2013. This is also the case for the total number of community and trust apportioned cases for the whole of Surrey. As a result, many Surrey trusts have exceeded their objectives. It is worth noting this Trust had the lowest objective in Surrey and continues to perform as one of the best Trusts for C.diff.

Reducing the number of inpatient falls has been (and continues to be) a strong focus for the Trust. In line with NICE guidance, patients are assessed on admission to establish their individual risk of falling. If a raised risk is identified, a falls care plan is implemented including initiating preventative measures such as using a falls monitor and appropriate footwear. Mobility is a very important aspect of a patient’s recovery and therefore we will be working with our health partners and the Surrey and Sussex Allied Health Science Network to seek innovative solutions to minimise both the risk and impact of a fall.

Clinical Outcomes

Our work on improving patient safety and clinical outcomes in order to reduce mortality rates continues to show significant benefits. The Trust has consistently reported one of the lowest mortality rates in the NHS, which means that fewer people die in our hospital than would reasonably be expected. The Trust achieved a Summary Hospital-level Mortality Indicator (SHMI) score of 73.07 in November 2013 (year to date score of 89.94), compared with a score of 91.58 for 2012-2013. SHMI scores are reported in arrears and reflects performance over the preceding 12 month period. Nationally, the expected score is 100 with a lower score indicating a better performing and safer trust.

The vascular service has moved to seven day consultant vascular surgeon availability for vascular emergencies with access to emergency theatres at any time. This service is supported by an interventional radiologist rota. This enables the Trust to provide a high quality service for our wide vascular catchment population. The Trust’s excellent surgical results are published as part of national data sets.

The Trust also operates an emergency orthopaedic trauma service with consultant surgeons available to operate seven days a week, supported by specialist spinal surgeons. We also have consultant cardiologists available to treat heart attacks 7 days a week, 365 days of the year. They treat more than 450 heart attacks a year, more than any comparable sized hospital locally. In addition we have a consultant physician available on-site for at least 12 hours a day and daily presence of respiratory specialists. We aim to extend this level of cover to all our major clinical specialties.

Patient Experience

Our staff are committed to providing first class care to every patient, every time. We know from the excellent results (see below) of the 2013 NHS staff survey and the comments made by the CQC in their inspection report that our staff are happy working for the Trust and continually demonstrate caring, committed and compassionate care. We were also very pleased to be accredited with Ones to Watch status in the Best Companies survey for 2014. This has given the Trust further assurance of the excellent levels of staff engagement as the survey results are benchmarked against non-NHS organisations.

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The Trust’s overall staff engagement score is in the best 20% of acute Trusts in 2013. This score is a combination of three key findings including the ability of staff to contribute to improvements at work, staff recommending the Trust as a place to work, and staff motivation at work.

The Trust’s score represents a year on year improvement in staff engagement as shown in the graph below.

There is increasing evidence in the healthcare setting that higher levels of staff engagement have a positive impact on clinical outcomes for patients. For example, a review by West and Dawson (2012) highlights a study by Prins and colleagues (2010) of more than 2000 Dutch doctors, which found that those

[staff] who were more engaged were significantly less likely to make mistakes. Similarly a study of 8000 nurses by Laschinger and Leiter (2006) found that higher engagement was linked to safer patient care. Additionally, West and Dawson (2012) compared engagement scores in the NHS Staff Survey with a wide range of outcome data. They showed that patient experience improves, inspection scores are higher, and infection and mortality rates are lower when there is strong staff engagement.

In April 2013, the NHS commenced reporting on the first phase of the national Friends and Family Test (FFT) for inpatients and those attending the Accident and Emergency department. When David Cameron announced the FFT he said: “Patients are going to be able to answer a simple question: whether they’d want a friend or relative to be treated there”. We are proud to say that due to the enthusiasm with which the test is being received by our patients, our response rate is one of the highest in the country. A total of 21,533 patients have participated in the FFT since April 2013, 94% (local data) of whom said that they would be ‘extremely likely’ or ‘likely’ to recommend our inpatient and accident and emergency services to their friends and family. A very small percentage (1.7%) of patients would not recommend the Trust. A significant proportion of patients who felt they would not recommend the Trust stated that this was because the Trust is not their local hospital. Unfortunately, at this stage of the FFT national programme, it is not possible to categorise these responses differently and therefore we acknowledge that the percentage of negative responses is higher than we would want to see. The challenge for 2014-2015 is to help our patients engage with the FFT more fully and encourage even greater numbers of patients to tell us whether they would recommend us to their friends and family.

Section three shows our performance month on month. Results are also published monthly on the Trust website.

We have put into place a rapid action mechanism in which comments (both good and bad) are fed back to the wards and the Accident and Emergency department in order that our staff can take prompt action to improve the care that our patients receive. Changes are subsequently monitored by the Patient Experience Forum, and ultimately by the Board and Governors. In October 2013 the maternity Friends and Family Test was introduced to give users of our maternity services the opportunity to give us real-time feedback on their experience of our antenatal, birth and postnatal care services. We are delighted to say that 3,472 women were generous enough to take part, 99% of whom said that they would be extremely likely or likely to recommend our maternity services. Our first set of results are presented in section three of this report and updated monthly on the Trust website.

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The Trust has defined the priority areas for improvement during 2014-2015 in section two of this report in conjunction with the Patient Experience and Involvement Group (PEIG). Section three details the progress we have made against stretch targets identified in last year’s report and against locally agreed quality indicators.

Response to the Francis, Keogh and Berwick Reports

In 2013Following the Francis report, the quality of care provided by the NHS came under the national spotlight. In February, the Prime Minister announced that he had asked Professor Sir Bruce Keogh [NHS Medical Director for England], to review the quality of care and treatment provided by those NHS trusts and NHS foundation trusts that were persistent outliers on mortality indicators.

Frimley Park Hospital NHS Foundation Trust has a very low mortality rate and was therefore not one of the trusts selected for investigation.

The Keogh investigation looked broadly at the quality of care and treatment provided across six key areas: mortality, patient experience, safety, workforce, clinical and operational effectiveness, and leadership and governance.

Keogh made the following observation in his letter to the Secretary of State: “We found pockets of excellent practice in all 14 of the trusts reviewed. However, we also found significant scope for improvement.” Although we [the Trust] are rightly proud of our achievements in safety and in the quality of care our patients receive, we remain vigilant and actively seek out warning signs. The Trust has therefore taken the following actions against the eight recommendations (ambitions) of the Keogh Mortality Review.

Ambition 1: We [the NHS] will have made demonstrable progress towards reducing avoidable deaths in our hospitals, rather than debating what mortality statistics can and can’t tell us about the quality of care hospitals are providing.

Actions: Morbidity and Mortality (M&M) Group in place to bring together all those with an interest in improving practice around morbidity and mortality outcomes, to ensure multi-professional learning is disseminated across specialties, and to monitor performance against these goals. The M&M Group will also provide assurance to the Board that all unexpected deaths are reviewed and specialty mortality trends examined.

The Medical Emergency Team (MET) scoring criteria and escalation process for the deteriorating patient has been fully embedded into practice.

One of the highest proportion of Consultant delivered care nationally out of hours and at weekends.

Monthly meetings with commissioners to review quality performance and work programmes.

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Ambition 2: The boards and leadership of provider and commissioning organisations will be confidently and competently using data and other intelligence for the forensic pursuit of quality improvement. They, along with patients and the public, will have rapid access to accurate, insightful and easy to use data about quality at service line level.

Actions: Regular attendance by nursing and medical staff at public Board meetings to answer questions about quality performance data for their areas of clinical responsibility.

Monthly Performance and Quality Board report in place to monitor national and local priorities, patient safety, clinical effectiveness and patient experience indicators.

New specialty Quality Dashboards developed to monitor performance against stretch targets in 2015-2016.

Quality impact assessments completed for all innovation and transformation programme initiatives to ensure that the quality of services is not adversely impacted as we work with other health and social care provider organisations and commissioners to deliver streamlined services.

Ambition 3: Patients, carers and members of the public will increasingly feel like they are being treated as vital and equal partners in the design and assessment of their local NHS. They should also be confident that their feedback is being listened to and see how this is impacting on their own care and the care of others.

Actions: The Trust holds constituency meetings once a month (with the exception of August and December) in different locations throughout the Trust catchment area. The constituency meetings are very well received with an average attendance of 105 people. Twice a year extended constituency ‘plus’ meetings are held which are even more popular and have an average of 250 people attending. All meetings are advertised in our newsletter which reaches over 11,000 public foundation trust members, on our website, and on our patient information touch screens in the main entrance foyer to the hospital.

The Director of Nursing chairs the monthly Patient Experience forum to review and identify actions from patients’ Friends and Family Test comments, complaints, and Patient Advice & Liaison Service comments.

Successful implementation of the national Friends and Family Test programme. Outcomes and actions are reported to, and monitored by, the Patient Experience Forum and ultimately the Board and Governors.

Ambition 4: Patients and clinicians will have confidence in the quality assessments made by the Care Quality Commission not least because they will have been active participants in inspections.

Actions: The Trust was selected as a low risk hospital to participate in the new style CQC inspection regime instigated as a result of these recommendations. Our inspection took place in November 2013 and the Trust received an overwhelmingly positive report.

Some of our staff are now participating in CQC inspections of other hospitals.

Ambition 5: No hospital, however big, small or remote, will be an island unto itself. Professional, academic and managerial isolation will be a thing of the past.

Actions: The Trust continues to benchmark its services locally, nationally and indeed internationally. A number of consultants have worked with the National Institute for Care Excellence (NICE) to develop Clinical Guidelines ensuring patients benefit from their expertise nationally.

The Board has been named national Board of the Year by the National Leadership Academy.

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Ambition 6: Nurse staffing levels and skill mix will appropriately reflect the caseload and the severity of illness of the patients they are caring for and be transparently reported by trust boards.

Actions: The Director of Nursing and Director of Operations have undertaken a patient to nursing ratio and skill mix review on a shift-by-shift basis. Nurse staffing levels have been reviewed for every ward and a further £2million has been invested to move to a 1:8 nurse-to-patient ratio for morning and afternoon shifts, and a 1:10 ratio for night shifts on all adult wards. Higher staffing ratios exist in critical areas as defined by the Intensive Care Society.

Ambition 7: Junior doctors in specialist training will not just be seen as the clinical leaders of tomorrow, but clinical leaders of today. The NHS will join the best organisations in the world by harnessing the energy and creativity of its 50,000 young doctors.

Actions: Peer reviews from the deanery were exceptional. CQC inspectors recognised the support and training that our junior doctors receive.

Health Education Kent, Surrey and Sussex positioned us as the top hospital for junior doctors in 2013.

Junior doctors regularly participate in M&M review meetings and clinical audits.

Ambition 8: All NHS organisations will understand the positive impact that happy and engaged staff have on patient outcomes, including mortality rates, and will be making this a key part of their quality improvement strategy.

Actions: Quality Strategy 2013-2016 in place.

Outstanding staff support for Trust values. The Trust chose to include additional questions on the Trust values into the national staff survey. The results revealed that 92% of staff understood them, 84% related to them, and 85% supported them.

Staff representatives sit on the Trust Council of Governors.

Specific comment received from the CQC in their inspection report regarding our ‘overwhelmingly happy’ staff and described them as ‘a workforce of dedicated staff caring for people.’

Berwick Report

In August 2013, the National Advisory Group on the Safety of Patients in England, chaired by Don Berwick published the Berwick report Improving the safety of patients in England.

Don Berwick distilled the report’s recommendations into a set of guiding principles and wrote: “I suggest, these [principles] should inform every step you take in these matters – in what you think, say, and do.”

• Place the quality of patient care, especially patient safety, above all other aims. • Engage, empower, and hear patients and carers at all times. • Foster whole-heartedly the growth and development of all staff, including their ability and support to

improve the processes in which they work. • Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the

growth of knowledge.

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We [the Trust] believe that Berwick is right and fully endorse and support the principles defined in his report. We take pride and joy in the professionalism, skill, care, compassion and empathy that our staff exhibit every day and will work to ensure that our staff have the confidence to challenge poor practice and know that they will be supported and encouraged to do so.

We believe that understanding good practice, rather than focusing excessively on poor practice, is the right way to drive improvement in patient care, and we aim to demonstrate good practice in everything we do.

We remain committed to a continual cycle of improvement and therefore, in partnership with our local commissioners, we have set ourselves some extremely challenging ambitions to further improve the quality and safety of our services. We believe that our patients, families, carers and staff deserve nothing less.

Conclusion

The Trust has continued to strengthen the quality of services provided for our community. Our staff continually demonstrate that they are committed to excellence and were recognised by the CQC for their compassion whilst delivering care to our patients, and their families and carers during a time when they may feel at their most vulnerable.

We recognise and acknowledge that we have work to do, and it is right that we continually strive to provide the safest care and best outcomes for our patients. Therefore, working in partnership with our commissioners, we have set ourselves challenging and stretching goals. We acknowledge that we may not reach all of them but we need to lead the way, challenging ourselves to be better and learning from others whenever we can. We will do this in order to achieve our often stated ambition to be recognised, locally and nationally, as a leader in quality healthcare, delivering safe, clinically effective services, focused entirely on the needs of our patients, their relatives and carers. Even when we are under pressure, excellence is our watchword and our values guide everything we do.

The Trust has a mechanism in place to identify any guidance issued by the Secretary of State (relating to chapter 2 of the Health Act 2009) and act upon it appropriately.

To the best of our knowledge, the information in the document is accurate.

Sir Mike Aaronson Andrew Morris Chairman Chief Executive 22 May 2014 22 May 2014

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Part 2:

2.1 Priorities for Improvement

2.2 Statement of assurance from the Board

This section of our quality report discusses the priorities we have chosen for 2014-2015. These have been agreed following discussion with patients, clinicians, governors and commissioners, and are based on the framework developed by Lord Darzi.

The priorities were finalised following a workshop discussion between the Trust Board of Directors (the Board) and the Council of Governors (the Governors) in January 2013 and the Trust Quality Strategy of 2013-2016.

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Part 2: 2.1 Priorities for improvement

Frimley Park Hospital NHS Foundation Trust (the Trust) will continue to build on previous achievements and the improvement priorities defined in the 2012-2013 Quality Report, the trust Quality Strategy 2013-2016 and the recommendations made by Lord Darzi. We will continue our journey to be identified as the local and national leader in quality healthcare, remaining focused on the three key areas of quality (patient safety, patient experience and clinical outcomes) as set out by Lord Darzi in order to deliver further improvements.

The detailed performance against the quality improvement priorities for 2013-2014 (as identified in last year’s report) are reported in part three.

2013-2014 Quality improvement priorities

As in previous years we will continue to monitor the indicators below in order to further improve quality:

Patient safety: Reducing the number of preventable harms with the aim of reducing harm by an additional 15% for C.diff, pressure ulcers and falls with significant harm by the end of 2015-2016.

In line with national requirements, we will continue to focus on improving the percentage of patients who have a venous thromboembolism (VTE) risk assessment completed and we will also continue to complete the NHS Safety Thermometer (NHS- ST), tool that measures harm from falls, pressure ulcers, VTE and catheter associated urinary tract infections.

Clinical outcomes: Sustain the Trust’s Summary Hospital Mortality Indicator (SHMI) and will continue to focus on stroke and transient ischaemic attack, vascular, cardiology, trauma and dementia.

Patient experience: Friends and Family Test and meeting inpatients’ essential care needs: o always treated with respect and dignity, o always given enough privacy when discussing their treatment/condition and o receive the required assistance (amalgamated measure: washing/dressing, eating/drinking

and mobilising)

2014-2015 priorities for improvement

Keeping patients safe is a fundamental and long standing commitment for the Trust and it is, as in previous years, the key rationale for the identified range of quality improvement indicators for 2014-2015.

In consultation with a wider public of stakeholders, we have identified that we will specifically, but not solely, focus on three trust wide indicators:

Sepsis

Catheter Associated Urinary Tract Infection

Acute Kidney Injury

To ensure that we further improve the quality of our services, we have set ourselves stretching targets for the year ahead. Performance against our priorities for improvement will be included in the Trust Performance & Quality Report which is reviewed by relevant committees on a regular basis and ultimately by the Board of Directors (the Board) and the Council of Governors (the Governors).

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Sepsis

Sepsis is a life-threatening illness caused by the body overreacting to an infection. The body’s immune system goes into overdrive, setting off a series of reactions that can lead to widespread inflammation (swelling) and blood clotting in the body.

Neutropenic sepsis is caused by a condition known as neutropenia, in which the number of white blood cells (called neutrophils) in the blood is low. Neutrophils help the body to fight infection. People having anticancer treatment, particularly chemotherapy and more rarely radiotherapy, can be at risk of neutropenic sepsis.

During 2013-2014, 248 patients were diagnosed with sepsis in the Trust, 58 of whom were neutropenic.

In 2012-2013 we started collecting data to establish a baseline for all patients with sepsis who receive antibiotics within one hour. The 2012-2013 data showed that we achieved an average compliance percentage for all septic patients receiving antibiotics within one hour of 33%.

For 2013-2014 the Trust Sepsis Steering Group and safety committee set a target of 50% for all sepsis patients and a progressive neutropenic septic patient target of 50% in quarter one, 75% in quarter two and 100% during quarters three and four. 2013-2014 performance is set out below.

Source: Trust data March 2014

The rationale for continuing the focus on sepsis is linked to the performance data presented above. From this data it is evident that we have substantially improved our practice from the baseline of 33% for all sepsis; however there is still room for improvement in order to reach our targets described above. The Sepsis Steering Group will drive the work to embed the pathway and oversee the training programme to identify rapidly, patients who develop a sepsis while in hospital.

Performance against these indicators is measured in the Trust wide Performance and Quality Report which is reviewed by relevant committees on a regular basis and ultimately by the Board and the Governors.

We are taking the following actions to improve performance:

continued meetings of the Sepsis Group,

continued training programme with targeted training sessions to relevant wards and skills blitz days,

audit sepsis pathway.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

All Sepsis Neutropenic Sepsis

56%

75%

65%

90%

61%68%

73%76%

64%72%

2013-2014 Sepsis Performance

Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTD

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A catheter-associated urinary tract infection (CAUTI) is an infection that occurs in someone who has a tube (called a catheter) in place to drain urine from the body. There is no national definition available, however at this Trust a decision is made using the following definition: A catheter-associated urinary tract infection (CAUTI) is an infection that occurs in the urinary system after a patient has had a catheter inserted.

A total of 1794 patients were reported as having a urinary catheter during 2013-2014, 1.9% of whom developed a urinary tract infection.

Source: NHS Safety Thermometer data March 2014

The rationale for remaining focused on catheter infections is to reduce the number of patients with a catheter associated urinary tract infection linked to inappropriate insertion. We intend to continue data collection against the following indicators:

The number of patients with a urinary catheter.

The number of patients who have the catheter inserted appropriately.

The number of patients who have a catheter associated urinary tract infection.

Performance against these indicators will be included in the Trust wide Performance and Quality Report which is reviewed by relevant committees on a regular basis and ultimately by the Board and the Governors.

We are taking the following actions to improve performance:

Policy has been reviewed to make it clearer whether a catheter is required.

Potential CAUTI cases have been pathology confirmed since July 2013.

Training on reducing CAUTIs has been included in patient safety training ‘harm free care’.

0%1%2%3%4%5%6%

Patients with aninappropriate catheter in

situ

Patients with a urinary tractinfection (Catheter

associated)

6%

2%

2013-2014 CAUTI Performance

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Acute Kidney Injury (AKI)

AKI is the rapid loss of kidney function.

In last year’s report we reported that extensive internal medical record audits had been undertaken for patients who passed away in our care or within 28 days of discharge. This audit highlighted that improvement could be made in the management of patients with an acute kidney injury. During 2013-2014 we collected data by using the national best practice tool and established three specific work streams.

The rationale for identifying AKI as a key priority for improvement is that there is further work to do to embed the pathway fully and to improve compliance. We also intend to develop an alert for the Pathology results system, (Winpath), to improve AKI recognition and diagnosis.

AKI Improvement Performance 2013-2014

Development of an AKI pathway. A pathway has been developed from the London AKI network pathway. This includes a care bundle checklist to enable the early recognition and treatment of AKI. The bundle also includes the complications of AKI and the appropriate medical interventions and management options for this. A base line audit was undertaken prior to the launch of the AKI pathway and a further audit was completed three months later. The results of the AKI management audit and re-audit have been presented at each directorate. Results are reported in part 3.

Development of medical staff training. A training program for the junior doctors has been in progress, facilitated by one of the lead patient safety clinicians.

An AKI scenario has been incorporated into simulation training for junior doctors. It is a top 20 teaching subject (twice yearly) and has been the subject of the bi-monthly Medical Directors briefing to trainees on two occasions. ID badge identification reminder/prompt cards have been developed for junior doctors and poster reminders about the AKI management checklists are displayed on every ward.

Development of nursing staff training on the recognition of AKI and appropriate monitoring. The AKI pathway was launched at the nursing skills blitz day in November 2013. The management and treatment of the AKI patient has been included in patient safety training for all registered nurses developed around a patient scenario. AKI training has also been incorporated into Alert training. The Preceptorship Program for nurses includes a session on AKI and the student nurses also undertake an AKI training session. Training for unregistered staff has been delivered via the care assistant induction and training programmes.

An audit of hospital deaths is undertaken twice a year using the global trigger tool (GTT) to monitor the incidence of AKI. Performance will be measured by an annual audit of compliance with the AKI pathway and will be reported to the AKI Steering Group which is chaired by the lead consultant for morbidity and mortality.

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Other quality indicators

During 2013-2014 the Trust achieved reductions in the numbers of harms and improved safety performance in the quality indicators shown in the tables below, which also shows the targets for 2014-2015.

PATIENT SAFETY

Indicator 2010-2011 2011-2012 2012-2013 2013-2014 Reduction/

Improvement* Target

2014-2015

C.diff 25 15 16 15 6% reduction 18

(National NHS England)

HA pressure ulcer grade two

243 247 144 88* 39%**

reduction 10% reduction

(Local) HA pressure ulcer grade three

16 13 15 7* 53%**

reduction

HA pressure ulcer grade four

4 2 0 0 Performance maintained

Zero tolerance

(Local)% falls resulting in significant injury by overall activity

0.10% 0.08% 0.03% 0.03% Performance maintained

10% reduction

(Local)

Average reduction in harm rate indicators above 20%

VTE % risk assessment 83% 91% 93% 97% 2%

improvement 95%

NHS-ST % harm free NA NA 93% 95% 2%

Improvement 95%

Average improvement in harm rate indicators above 3%

Source: Trust data, March 2014. *Improvement calculated against 2012-2013 outturn.

**February 2014 data.

2013-2014 performance for MRSA increased from one in 2012-2013 to four. Following in depth reviews of each case, only one bacteraemia was recorded as avoidable. Further details are given in part three.

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Part 2: 2.2 Statements of assurance from the Board

During 2013-2014 the Frimley Park Hospital NHS Foundation Trust (the Trust) provided and/or sub-contracted 34 relevant health services.

The Trust has reviewed all the data available to them on the quality of care in 34 of these relevant services.

The income generated by the relevant health services reviewed in 2013-2014 represents 100 per cent of the total income generated from the provision of relevant health services by the Trust for 2013-2014.

During 2013-2014 31 national clinical audits and 4 national confidential enquiries covered relevant health services that the Trust provides.

During 2013-2014 the Trust participated in 97% national clinical audits and 100% of national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.

The national clinical audits and national confidential enquiries that the Trust was eligible to participate in during 2013-2014 are as follows:

1. Diabetes (paediatric) 2. Epilepsy 12 audit (childhood epilepsy) 3. Neonatal intensive and special care (NNAP) 4. Paediatric asthma (British Thoracic Society) 5. Congenital heart disease (paediatric cardiac surgery (CHD)) – Not performed at the Trust 6. Paracetamol overdose (care provided in Emergency Departments (ED)) 7. Severe sepsis & septic shock (College of Emergency Medicine) 8. Severe trauma (Trauma Audit & Research network, TARN) 9. Moderate or severe asthma in children (care provided in ED) 10. National audit of seizure management (NASH) 11. Emergency use of oxygen (British Thoracic Society) 12. Case mix programme 13. Medical and surgical clinical outcome review programme: National confidential enquiry into patient outcome and death

(NCEPOD) 14. National emergency laparotomy audit (NELA) 15. National joint registry (NJR) 16. National comparative audit of blood transfusion programme (multi audit programme) 17. National chronic obstructive pulmonary disease (COPD) audit programme (Royal College of Physicians) 18. Diabetes (adult) includes national diabetes inpatient audit (NADIA) 19. Inflammatory bowel disease (IBD) 20. Sentinel stroke national audit programme (SSNAP) 21. Rheumatoid and early inflammatory arthritis 22. Bowel cancer (NBOCAP) 23. Head and neck oncology (DAHNO) 24. Lung cancer (NLCA) 25. Oesophago-gastric cancer (NAOGC) 26. Acute coronary syndrome or acute myocardial infarction (MINAP) 27. Adult cardiac surgery (ACS) – not performed at the Trust 28. Cardiac rhythm management (CRM) 29. Coronary angioplasty (BCIS) 30. Heart failure (HF) 31. National cardiac arrest audit (NCAA) 32. Pulmonary hypertension audit 33. National vascular registry 34. A: Falls and Fragility Fractures Audit Programme (FFFAP): Fracture Liaison Service Database – service not provided

B. Falls and fragility fractures audit programme (FFFAP): Hip Fracture Database 35. Elective surgery (National PROMs programme) 36. Maternal, newborn and infant clinical outcome review programme (MBRRACE-UK)

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The national clinical audits and national confidential enquiries that the Trust participated in during 2013-2014 are as follows:

1. Diabetes (paediatric) 2. Epilepsy 12 audit (childhood epilepsy) 3. Neonatal intensive and special care (NNAP) 4. Paediatric asthma (British Thoracic Society) 5. Paracetamol overdose (care provided in Emergency Departments (ED)) 6. Severe sepsis & septic shock (College of Emergency Medicine) 7. Severe trauma (Trauma Audit & Research network, TARN) 8. Moderate or severe asthma in children (care provided in ED) 9. National audit of seizure management (NASH) 10. Emergency use of oxygen (British Thoracic Society) 11. Case mix programme 12. Medical and surgical clinical outcome review programme: National confidential enquiry into patient outcome and death

(NCEPOD) 13. National emergency laparotomy audit (NELA) 14. National joint registry (NJR) 15. National comparative audit of blood transfusion programme (multi audit programme) 16. National chronic obstructive pulmonary disease (COPD) audit programme (Royal College of Physicians) 17. Diabetes (adult) includes national diabetes inpatient audit (NADIA) 18. Inflammatory bowel disease (IBD) 19. Sentinel stroke national audit programme (SSNAP) 20. Rheumatoid and early inflammatory arthritis 21. Bowel cancer (NBOCAP) 22. Head and neck oncology (DAHNO) 23. Lung cancer (NLCA) 24. Oesophago-gastric cancer (NAOGC) 25. Acute coronary syndrome or acute myocardial infarction (MINAP) 26. Cardiac rhythm management (CRM) 27. Coronary angioplasty (BCIS) 28. Heart failure (HF) 29. National vascular registry 30. Falls and Fragility Fractures Audit Programme (FFFAP): National Hip Fracture Database. 31. Elective surgery (National PROMs programme) 32. Maternal, newborn and infant clinical outcome review programme (MBRRACE-UK)

The national clinical audits and national confidential enquires that the Trust participated in, and for which data collection was completed during 2013-2014, 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.

1. Diabetes (paediatric) 100% 2. Epilepsy 12 audit (childhood epilepsy) 100% 3. Neonatal intensive and special care (NNAP) 100% 4. Paediatric asthma (British Thoracic Society) 100% 5. Paracetamol overdose (care provided in Emergency Departments (ED)) 100% 6. Severe sepsis & septic shock (College of Emergency Medicine) 100% 7. Severe trauma (Trauma Audit & Research network, TARN) 100% 8. Moderate or severe asthma in children (care provided in ED) 100% 9. National audit of seizure management (NASH) 100% 10. Emergency use of oxygen (British Thoracic Society) 100% 11. Case mix programme 100% 12. Medical and surgical clinical outcome review programme:

National confidential enquiry into patient outcome and death (NCEPOD) 100% 13. National emergency laparotomy audit (NELA) Data collection phase 14. National joint registry (NJR) 99% 15. National comparative audit of blood transfusion programme

(multi audit programme) 100% 16. National chronic obstructive pulmonary disease (COPD) audit programme

(Royal College of Physicians) Data collection phase 17. Diabetes (adult) includes national diabetes inpatient audit (NADIA) 100% 18. Inflammatory bowel disease (IBD) 100% 19. Sentinel stroke national audit programme (SSNAP) 100%

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20. Rheumatoid and early inflammatory arthritis Data collection phase 21. Bowel cancer (NBOCAP) 100% 22. Head and neck oncology (DAHNO) 100% 23. Lung cancer (NLCA) 100% 24. Oesophago-gastric cancer (NAOGC) 100% 25. Acute coronary syndrome or acute myocardial infarction (MINAP) 100% 26. Cardiac rhythm management (CRM) 100% 27. Coronary angioplasty (BCIS) 100% 28. Heart failure (HF) 100% 29. National vascular registry 100% 30. Falls and Fragility Fractures Audit Programme (FFFAP): National Hip Fracture Database 100% 31. Elective surgery (National PROMs programme) 97% 32. Maternal, newborn and infant clinical outcome review programme

(MBRRACE-UK) 100%

The reports of 22 national clinical audits were reviewed by the provider in 2013-2014 and the Trust intends to take the following actions to improve the quality of healthcare provided.

Detailed in the annual Audit Report to Clinical Governance committee. Includes summary of findings and agreed actions and changes in practice. Eg: National Hip Fracture Database (NHFD): Continue to work on pressure ulcers using the care bundle.

Each Directorate presents prioritised their audit plan and reviews progress against actions plans as part of their clinical governance arrangements for audit.

The reports of 175 local clinical audits were reviewed by the provider in 2013-2014 and the Trust intends to take the following actions to improve the quality of healthcare provided.

Detailed in the annual Audit Report to Clinical Governance committee. Includes summary of findings and agreed actions and changes in practice. Eg: ICU delirium study (baseline and reaudit): Hold study days to reinforce key concepts on how to manage delirium patients.

Reviewed by the Clinical Audit and Effectiveness Committee and team.

Each Directorate presents prioritised their audit plan and reviews progress against actions plans as part of their clinical governance arrangements for audit.

The number of patients receiving relevant health services provided or sub-contracted by the Trust in 2013-2014 that were recruited during that period to participate in research approved by a research ethics committee was 1,367.

Participation in clinical research demonstrates the Trust’s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. The Trust was involved in conducting 125 clinical research studies in 18 medical specialties (anaesthetics, dermatology, care of the elderly, diabetes, cardiology, vascular, gastroenterology, hepatology, stroke, nursing, paediatrics, neurology, obstetrics and gynaecology, ophthalmology, orthopaedics, pathology and urology) during 2013-2014.

A proportion of the Trust’s income in 2013-2014 was conditional on achieving quality improvement and innovation goals agreed between the Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework.

Further details of the agreed goals for 2013-2014 and for the following 12 month period are available electronically at www.frimleypark.nhs.uk/about-us/publications

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The Trust received income as a result of achieving the quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework as follows:

2012-2013 - £4.4m

2013-2014 - £5.9m (projected)

The Trust is required to register with the Care Quality Commission and its current registration status is unconditional. The Trust has the following conditions on registration: none.

The Care Quality Commission has not taken enforcement action against the Trust during 2013-2014.

The Trust has not participated in any special reviews or investigations by the Care Quality Commission during 2013-2014.

The Trust submitted records during 2013-2014 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:

• 99.0% for admitted patient care; • 99.8% for out patient care; and • 98.7% for accident and emergency care.

- which included the patient’s valid General Medical Practice Code was: • 99.8% for admitted patient care; • 99.9% for outpatient care; and • 99.4% for accident and emergency care.

The Trust’s Information Governance Assessment Report overall score for 2013-2014 was 75% and was graded Red, not satisfactory. A comprehensive work programme for 2014-2015 has been developed to increase the Trust’s information governance toolkit score.

The Trust was not subject to the Payment By Results clinical coding audit during the reporting period by the Audit Commission.

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Reporting against core indicators:

Since 2012-2013 NHS foundation trusts have been required to report performance against a core set of indicators using data made available to the trust by the Health and Social Care Information Centre (HSCIC).

The following tables show our performance for at least the last two reporting periods and where the data is made available by the HSCIC, a comparison with the national average and the highest and lowest performing trusts is given. The Trust’s locally generated data, where applicable, is also shown.

SHMI

Prescribed information: a) the value and banding of the summary hospital-level mortality indicator (SHMI) for the trust for the

reporting period; and b) the percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the

trust for the reporting period is included to give context.

Indicator and Scope Prior Period Latest Period Data Source

Summary Hospital-Level Mortality Indicator (SHMI):

Apr 2012 - Mar 2013 Jul 2012 - Jun 2013 HSCIC (Health and Social Care Information

Centre)

Indicator IDs P01638 & P01648

FPH Trust 0.9097

‘As expected’ 0.9277

‘As expected

Trusts national average 1.00 1.00

Highest (worst) and lowest (best) trust scores

1.1697 / 0.6523 1.1563 / 0.6259

Jan 2012 - Dec 2012 Jan 2013 - Dec 2013

HED* (Healthcare

Evaluation Data)

FPH Trust 0.8991 0.8845



1.1905 / 0.7011 1.1486 / 0.6087

*A national reporting and comparison system containing Hospital Episode Statistics (HES) data as the primary source and utilises HSCIC Information Centre data

The Trust considers that this data is as described for the following reasons:

Taken from national dataset using data provided.

The Trust has taken the following actions to improve this indicator, and so the quality of its services, by:

Strengthened morbidity and mortality (M&M) process to oversee, monitor, review and report on the findings of the Specialty M&M reviews. Trust M&M review group chaired by a consultant patient safety lead on behalf of the Medical Director.

The clinical issues identified through the M&M review process inform a number of safety workstreams and progress against these are monitored through the Trust Quality Committee chaired by the Medical Director. The Medical Director subsequently provides assurance to the Board.

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Palliative Care Indicator Percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the Trust for the reporting period.

Apr 2012 - Mar 2013 Jul 2012 – Jun 2013 HSCIC (Health and Social Care Information

Centre)

Indicator IDs P01640 & P01650

FPH Trust 30.1% 31.1%

Trusts national average 19.9% 20.3%


44.0% / 0.1% 44.1% / 0%




The Trust has always been committed to delivering high quality end of life care for patients dying in hospital. The specialist palliative care team (SPCT) has a high profile across the Trust and includes a dedicated end of life care nurse as a key member. The end of life care nurse actively accesses dying patients referred to her and seeks the support of the SPCT for advice around symptom management and important decisions around nutrition and hydration at the end of life if required.

The SPCT has a high profile across the hospital resulting in an increasing number of patient contacts/assessments. Patient contacts with either the specialist palliative care team or the end of life care nurse are coded as palliative (with the Z51.5 code) whenever an appropriate entry is made in the patient’s medical records. Therefore as the Trust is coding more accurately we believe that this may result in a higher score.

Robust identification of palliative care input and the subsequent coding has improved since 2011 when the SPC tariff was introduced.

The activity of the specialist palliative care team at the Trust in 2012-2013 is higher than the regional median. FPH SPCT has a significantly higher percentage of new patients over the age of 84 compared with other similar large trusts in the region. This population has higher morbidity and mortality. Therefore we believe that the Trust may have more end of life patients.

The increase in the number of inpatient deaths supported by the SPCT provides the Trust with reassurance that palliative care needs of those patients and their carers will be fully assessed and addressed.

From April 2014 a monthly palliative coding report will be introduced to monitor and ensure that the appropriate patients are being coded correctly. The Somerset database records all the palliative care activity including the number of discharges and deaths of patients reviewed by the Palliative Care team.

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Patient Reported Outcomes Measures (PROMS) following hip or knee replacement surgery

Prescribed information:

The Trust’s patient reported outcome measures scores for; groin hernia surgery, varicose vein surgery, hip replacement surgery, and knee replacement surgery, during the reporting period.


Patient Reported Outcome Measures (PROMs): FY 2012-2013 Apr-Dec 2013

HSCIC (Health and Social Care Information

Centre)

Indicator ID P01387

Groin surgery - FPH Trust 0.075 0.081 Groin surgery - trusts national average 0.085 0.086 Groin surgery - highest (best) and lowest (worst) trust scores

0.153 / 0.014 0.158 / 0.013

Varicose vein surgery - FPH Trust 0.088 No score –

insufficient data

Varicose vein surgery - trusts national average 0.093 0.101

Varicose vein surgery - highest (best) and lowest (worst) trust scores

0.176 / 0.015 0.158 / 0.020

Hip replacement surgery - FPH Trust 0.429 0.424 Hip replacement surgery - trusts national average 0.438 0.439 Hip replacement surgery - highest (best) and Lowest (worst) trust scores

0.539 / 0.319 0.527 / 0.301

Knee replacement surgery - FPH Trust 0.319 0.298 Knee replacement surgery - trusts national average 0.318 0.330 Knee replacement surgery - highest (best) and lowest (worst) trust scores

0.416 / 0.209 0.416 / 0.193

The Trust considers that this percentage is as described for the following reasons:


The Trust introduced PROMs in 2009 for patients who had hip and knee replacement surgery, groin hernia and varicose vein surgery. These measure a patient’s health gain after surgery. The information is gathered from the patient who completes a questionnaire before and after surgery. The responses are analysed by an independent company and benchmarked against other Trusts. In order to make comparisons meaningful, a method is required to adjust for different patient profiles. These specific adjustments are based on statistical models which predict outcomes taking account of patient characteristics and factors which are beyond the control of providers. Using this method does not explain why differences across providers exist but allows valid comparisons among them. The Trust performance for all procedures sits within the control limits. The case mix adjusted average health gain shows that the Trust is not an outlier when compared nationally.


Consultant Orthogeriatrician appointed to improve pre-operative assessment and post-operative care. Enhanced Recovery Programme in place for both hip and knee replacement surgery. Patients who are admitted for hip surgery are cared for within a dedicated environment. Care is

provided by a dedicated and appropriately skilled multi-disciplinary team. Reiteration that post op instructions must be clearly documented regarding post-operative mobility.

All patients have documented care plan for post-operative mobility. Introduction of hydration, nutritional and falls assessment pre-operatively to ensure that patients are

in optimal nutritional health at the time of surgery. Patients who are at risk of falling receive appropriate support on admission.

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Readmissions rate for children and adults


The percentage of patients aged— (i) 0 to 15; and (ii) 16 or over,

Readmitted to a hospital which forms part of the Trust within 28 days of being discharged from a hospital which forms part of the Trust during the reporting period.


Readmissions within 28 Days – Under 16: Percentage of patients aged 0 to 15 readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period

FY 2010-2011 FY 2011-2012 HSCIC

(Health and Social Care Information

Centre)

Indicator ID P00913

FPH Trust 7.46% 8.55% Medium Acute Trusts national average 9.87% 10.04% Highest (worst) and lowest (best) Medium Acute Trust %s

14.34% / 0.0% 13.58% / 0.0%

FY 2012-2013 FY 2013-2014 Trust’s Data

FPH Trust 7.97% 8.37%

Indicator and scope Prior Period Latest Period Data Source

Readmissions within 28 Days –16 or over: Percentage of patients aged 16 or over readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period

FY 2010-2011 FY 2011-2012 HSCIC

(Health and Social Care Information

Centre)

Indicator ID P00904

FPH Trust 11.45% 12.02%

Medium Acute Trusts national average 11.17% 11.26%

Highest (worst) and lowest (best) Medium Acute Trust %s

13.00% / 0.0% 13.50% / 0.0%

FY 2011-2012 FY 2012-2013 (11 months) Trust’s Data

FPH Trust 12.17% 11.87% The Trust considers that these percentages are as described for the following reasons:



Dedicated phone line for patients to contact the clinical team if they have concerns after discharge.

Facility to bring patients back to a dedicated area and be seen by a consultant to avoid being readmitted.

Discharge information pack including leaflets, telephone number of who to contact for assistance.

Frimley Outreach Rehabilitation team (FORT). Can visit at home where necessary.

Paediatric Assessment Unit. Families given an ‘SOS’ card on discharge and have access to specialist paediatric advice and support 24 hours a day, seven days a week.

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Patient experience score for responsiveness to the personal needs of patients


The trust’s responsiveness to the personal needs of its patients during the reporting period.


Responsiveness to inpatients’ personal needs

FY 2012-2013 FY 2013-2014 HSCIC (Health and Social Care Information

Centre)

Indicator ID P01391

FPH Trust 68.9 70.1


Highest and Lowest Trust %s 85.0 / 56.5 84.4 / 57.4



The Trust has taken the following actions to improve this indicator, and so the quality of its services by:

Detailed in the Trust Board Patient Experience reports.

Reviewed staffing levels and skill mix for every inpatient area.

Established a Ward Leadership Programme to ensure senior Sisters have the skills and confidence to drive forward quality on their wards.

Established a Health Care Assistants competency programme.

Ward level monitoring of patient feedback via the Patient Experience Group.

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National Staff Survey – Recommend to Friends and Family

Percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends. (Responding agree and strongly agree)

2012 Survey 2013 Survey

NHS Staff Survey Indicator ID

P01554 FPH Trust 84% 85%

Acute & acute specialist trust’s national average 65% 67%

Acute & acute specialist trust’s highest (best) and lowest (worst) trust scores

94% / 35% 94% / 40%


National data.


The Director of Nursing and Director of Operations have undertaken a patient to nursing ratio and skill mix review on a shift-by-shift basis. Nurse staffing levels have been reviewed for every ward and a further £2million has been invested to move to a 1:8 nurse-to-patient ratio for morning and afternoon shifts, and a 1:10 ratio for night shifts on all adult wards. Higher staffing ratios exist in critical areas as defined by the Intensive Care Society.

New Leadership Development programme established for Ward Sisters and Practice Development Team in place to support staff with quality and safety standards which improves staff confidence in the level of care they are able to provide for patients.

Significant investment in research and development leading to more patients having access to cutting edge treatments through participation in clinical trials.

Open and interactive Chief Executive and Board sessions for staff to update them on Trust safety and quality initiatives and performance.

Established monthly dashboards to monitor patient satisfaction levels and therefore the quality and safety of services experienced during their admission.

Feedback from patients is reviewed monthly by the Patient Experience Group. Actions taken as appropriate and shared with ward staff by ward sisters to highlight issues and changes to practice.

The Trust achieved the Investors in People Bronze award in 2013 in recognition of the excellent and comprehensive communication, induction and training systems in place. Bronze status is only awarded to the top 5% of Investors in People organisations.

Established four apprenticeship programmes for Healthcare Assistants and Diploma in Health Care. The programmes are designed to equip Care Assistants with the necessary training and knowledge to deliver safe care and improve the quality of care delivered.

Implementation of the Customer Service Strategy which articulates the Trust’s values [committed to excellence, working together and facing the future]. The success of the strategy has been evidenced by the results of a local question added to the national staff survey. A remarkable 92% of staff said that they understood the new values. Additionally, almost 100% of managers and over 1400 front-line staff have received customer service training over the last 12 months.

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National Friends and Family Test (FFT)

Non statutory indicator:

The FFT response rate and net promoter score (NPS) for:

Inpatients

Accident and Emergency Maternity

FFT response rate FY 2013-2014

Trust’s data FPH Trust: Inpatient Accident and Emergency

37% 24%

FFT Net Promoter Score (NPS) FY 2013-2014

Trust’s data FPH Trust: Inpatient Accident and Emergency

77 53

FFT response rate: Oct 2013 – March 2014

Trust’s data

FPH Trust: Antenatal Care (In hospital) Antenatal Care (Community) Birth (In hospital) Home Birth Postnatal Care (In hospital) Postnatal Care (Community)

18% 29% 36% 32% 52% 37%

87

FFT Net Promoter Score (NPS) Oct 2013 – March 2014

Trust’s data

FPH Trust: Antenatal Care (In hospital) Antenatal Care (Community) Birth (In hospital) Home Birth Postnatal Care (In hospital) Postnatal Care (Community)

87 82 87 79 79 89


Trust data submitted to the national programme via the Unify2 system.


Established weekly dashboards to monitor the rate of response.

Established monthly dashboards to monitor the national promoter score.

Feedback from patients is reviewed monthly by the Patient Experience Group. Actions taken as appropriate and shared with ward staff by ward sisters to highlight issues and changes to practice.

Results published via the Trust website.

Results shared with staff via monthly reports.

Established a Ward Leadership Programme to ensure senior Sisters have the skills and confidence to drive forward quality on their wards.

Established a Health Care Assistants competency programme.

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Venous thromboembolism (VTE blood clot)


The percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.


Percentage of admitted who were admitted to hospital and who were risk-assessed for venous thromboembolism

Q2 2013-2014 Q3 2013-2014 HSCIC (Health and Social Care Information

Centre)

Indicator ID P01556

FPH Trust 96.9% 97.6%

Trusts national average 95.7% 95.8%

Highest (best) and lowest (worst) trust %s

100% / 81.7% 100% / 77.7%

FY 2012-2013 FY 2013-2014

11 months Trust’s Data

FPH Trust 92.94% 97.12%




Continued training and education of all relevant clinical staff groups.

Monthly monitoring report on performance by specialty. Actions monitored by the VTE Committee.

Improved patient information education and discharge advice regarding preventing VTE following discharge.

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Clostridium difficile (C.diff) infection


The rate per 100,000 bed days of cases of C.diff infection reported within the Trust amongst patients aged 2 or over during the reporting period.


Rate per 100,000 bed days of C.diff infection that have occurred within the trust amongst patients aged 2 or over

FY 2011-2012 FY 2012-2013 HSCIC (Health and Social Care Information

Centre)

Indicator ID P01557

FPH Trust 8.3 8.5

Trusts National Average 21.8 17.3

Highest (worst) and Lowest (best) Trust Scores

58.2 / 0.0 30.6 / 0.0

The Trust considers that this rate is as described for the following reasons:


The Trust has taken the following actions to improve this percentage, and so the quality of its services, by:

Formal root cause analysis meetings (chaired by the Medical Director, Director of Nursing and Quality or the Director of Infection Prevention and Control) take place for every ‘post 72 hour’ C.diff case. Learning is fed back to care groups and assurance of progress on actions is an agenda item at monthly Hospital Infection Control Committee meetings and monitored by the Trust Board.

As well as formal quarterly Trust wide antibiotic audits, a process of “Short timeframe” antibiotic audits (which are completed by every Directorate every 2 months) are in place and are presented at monthly Hospital Infection Control Committee (HICC) meetings. The Consultants who carry out the audits have confirmed how they feedback results to their Directorates, to assure the HICC. Results are also presented by Consultant.

All C.diff positive samples are sent to the reference laboratory for Ribotyping to determine whether there has been any cross infection.

Performance is scrutinised at monthly Hospital Infection Control Committee meetings, which is attended by a Governor, the Consultant for Communicable Disease Control (attends quarterly) and the lead Consultant for each Directorate. At the January 2014 committee meeting, 100% of Lead Consultants were in attendance.

The Consultant caring for any patient who has “hospital associated” C.diff or MRSA bacteraemia attends a Board of Directors meeting to discuss the case and to describe any learning from Root Cause Analysis.

Infection Control Nurses visit every ward bay on Monday to Friday mornings to identify if any patient has diarrhoea. They then remind staff to get prompt collection of stool specimens, and to ensure the patient is safely placed in a single room with their own toilet facilities.

Infection Control Nurses check stool specimens have reached the lab in time for 11.30am testing daily. They then remind staff to get prompt collection of a stool specimen if one has not been received, and ensure any patient who has had a stool sample sent to the lab is placed in a single room with their own toilet facilities.

35

In April, daily ward rounds were introduced for any patient at high risk from C.diff (i.e. those over 70 years, an in-patient for more than two weeks, and on antibiotics for seven days or more). Referrals for this ward round are made by ward Pharmacists. The Infectious Diseases Pharmacist assesses each referral and if required sends an email requesting a review and report of the actions taken to the Consultant in charge of the care for each referral.

A ‘checklist’ reminder was trailed in the respiratory ward by the Infection Control Lead Consultant for the Medical Directorate. This has demonstrated improved compliance with the antimicrobial prescribing care bundle and is expected to be rolled out to the entire Medical Directorate.

There is an on-going robust programme of monthly hand hygiene audits for every ward in the Trust. These are reported at monthly Hospital Infection Control Committee meetings, in bi-monthly reports to the Trust Board, in quarterly reports to the Clinical Governance Committee and as part of the Matrons and Clinical Directors reports on Infection Control to the Trust Board:

- Monthly audits of staff compliance with the ‘5 moments for hand hygiene’ procedure are conducted by Clinical Matrons.

- Audit of staff compliance with the ‘5 moments for hand hygiene’ for any ward where a case of C.diff has been confirmed is conducted by the Infection Control Team.

- Six monthly audits of staff compliance with the ‘5 moments for hand hygiene’ as part of a rolling audit programme to cover every ward and clinical area is conducted by the Infection Control Team. The Trust wide score for February = 96%

- Quarterly audit of patients’ hand hygiene is conducted by Clinical Matrons (to ensure patients are reminded or helped to clean their hands before eating and after using the toilet). The Trust wide score for January – March = 99.7% (before meals) and 98% (after using the toilet).

Quarterly ‘commode cleanliness’ spot checks are carried out Trust wide. Ward Housekeeping supervisor ‘Cleaning audit’ scores are presented (RAG’ed) as part of the Facilities

quarterly written report to the HICC.

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Patient safety incidents


The number and, where available, rate of patient safety incidents reported within the Trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death.

Indicator and Scope Prior Period NRLS Data

Current PeriodNRLS Data

Latest Period Trust’s Data

Data Source

Rate of patient safety incidents that occurred within the trust (100 admissions).

Apr 2012-Sep 2012

Apr 2013-Sept 2013

FY 2013-2014 HSCIC (Health and Social Care Information

Centre)

Trust’s data

FPH Trust 5.58 5.77 4.95%


14.44 / 3.11 14.49 / 3.54 N/A




Data Source

Number of such patient safety incidents reported that resulted in severe harm or death.

Apr 2012-Sep 2012

Apr 2013-Sept 2013

FY 2013-2014

HSCIC (Health and Social Care Information

Centre)

Trust’s data FPH Trust 9

(6 months) 8

(6 months) 20

(12 months)




Data Source

Percentage of such patient safety incidents reported that resulted in severe harm or death.

Apr 2012-Sep 2012

Apr 2013-Sept 2013

FY 2013-2014 HSCIC (Health and Social Care Information

Centre)

Trust’s data

FPH Trust 0.4% 0.4% 0.43%


3.6% / 0.0% 3.1% / 0.0% N/A

The difference between the NRLS data and the Trust data is as a result of the NRLS data covering between April 2013 and September 2013. The Trust data covers from April 2013 to March 2014.

The Trust considers that this number and/or rate is as described for the following reasons:



Detailed in the Trust quarterly safety reports.

Reviews undertaken to identify trends and areas for improvement.

Patient safety workstreams include:

Falls.

Pulmonary embolism.

Sepsis.

Deteriorating patient.

Opiate awareness.

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Part 3: Other Information 3.1 Review of Trust Quality Performance 2013-2014

This section provides an overview of the quality of care offered by the Trust based on performance in 2013-2014 against indicators selected by the Board in consultation with stakeholders, together with an explanation of the underlying reason for selection.

Wherever possible the data is shown over time in order that the reader can understand the progress made and compare the Trust’s performance with other providers (hospitals).

38

Review of Quality Performance 2013-2014

Patient Safety

During 2013-2014, Frimley Park Hospital NHS Foundation Trust (the Trust) has continued to focus on improving practice in a number of patient safety areas and has established a number of improvement projects with the aim of reducing preventable harm as defined in the Quality Strategy 2013-2016.

Rationale for inclusion: In our previous Quality Strategy the Trust set out to reduce preventable harm by 30% over three years and actually reduced harm by 53% (average). In last year’s report, we stated that it was our intention to reduce preventable harm by a further 15% (average) by the end of the new three year Quality Strategy 2013-2016 in order to realise our ambition to become the safest NHS trust nationally.

As reported in part 2, the Trust has made significant progress towards achieving the patient safety stretch target reduction of 15% by the end of 2015-2016. Performance against individual patient safety indicators is shown in the table below.

Indicator 2010-2011 2011-2012 2012-2013 2013-2014 Trend Over Time*

MRSA*** (Number of avoidable cases)

3 2 1 4

(1)

C.diff 25 15 16 15

Pressure Ulcers Grade 2

243 247 144 88**


16 13 15 7**


4 2 0 0**

% of falls resulting in significant injury

0.10% 0.08% 0.03% 0.03%


NHS Safety Thermometer (NHS ST) % Harm Free Care

NA NA 93% 95%

*Trend over time relates to 2010-2011 data **Data period April 2013 – February 2014

Source: Trust Performance Data & NHS Safety Thermometer data, March 2014

***MRSA bacteraemias are reviewed at a root cause meeting to determine whether each case was either avoidable or unavoidable. 2013-2014 results: 1 avoidable and 3 unavoidable.

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Sepsis

Sepsis is a life-threatening illness caused by the body overreacting to an infection. The body’s immune system goes into overdrive, setting off a series of reactions that can lead to widespread inflammation (swelling) and blood clotting in the body.

Rationale for inclusion: The rationale for focusing on sepsis is linked to the baseline performance data presented below. From this data it was evident that we should continue to focus on improving practice.

This year we continued to build on the work reported in the 2012 and 2013 Quality Reports. As part of the deteriorating patient work stream and with the rationale of further reducing preventable harm, we developed a Trust wide sepsis pathway and commenced measurement of our performance against the two national standards for the provision of antibiotics in sepsis:

Neutropenic sepsis. A condition known as neutropenia, in which the number of white blood cells (called neutrophils) in the blood is low:

Patients should receive antibiotics within 60 minutes.

Other sepsis (excludes neutropenic patients):

Patients should receive antibiotics within four hours.

Indicator (New)

Baseline Apr 2013

Qtr 1 Qtr 2 Qtr 3 Qtr 4 Trend over

time*

Sepsis - all (Number of patients)

48% 56% (32/57)

65% (34/52)

61% (46/75)

73% (47/64)

Sepsis –Neutropenic (Number of patients)

N/A 75% (6/8)

90% (9/10)

68% (13/19)

76% (16/21)

n/a

*Trend over time relates to baseline position (April 2013) Source: Trust data March 2014

40


A catheter associated urinary tract infection (CAUTI) is an infection that occurs in someone who has a tube (called a catheter) in place to drain urine from the body (no agreed national definition is available).

Rationale for inclusion: The rationale for remaining focused on CAUTI is linked to the data collected, which identified that 2% of patients with a urinary catheter had had this inserted inappropriately and that therefore this remains an area for improvement. In the 2012-2013 quality report we said that we would continue the data collection on the number of patients with a urinary catheter, the number who have the catheter inserted appropriately, as well as the number of those patients who have antibiotics prescribed for an indicated urinary tract infection (UTI) while having a urinary catheter in situ. We intend to collect the data against the last indicator by also using pathology data to determine the infection. The data will be collected alongside the monthly NHS-Safety Thermometer audit to establish whether a catheter is inserted appropriately we have agreed with lead clinicians and our commissioners a list of ten clinical indications for catheterisation.

The NHS Safety Thermometer (NHS ST) is an improvement tool for measuring, monitoring, and analysing patient harm and harm free care for Venous Thromboembolism (VTE), pressure ulcers, falls, and urinary catheter associated infection. The NHS-ST is governed by national standardised definitions.

Indicator Baseline 2012-2013 June - Mar

2013-2014 Trend over

time* Urinary Catheter: % of patients with an inappropriate urinary catheter in situ (ST audit)

March 2012 6%

2% 6%

Urinary Catheter: % of patients with a urinary tract infection due to urinary catheter (ST audit)

June 2012 29%

6% 2%

*Trend over time relates to the baseline position Source; Safety Thermometer data, March 2014

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Acute Kidney Injury (AKI)

AKI is a serious condition resulting in a loss of kidney function.

Rationale for inclusion: Extensive internal medical record audits have been undertaken for patients who passed away in our care or within 28 days after discharge. This has highlighted that improvements can be made in the management of patients with AKI in the following areas:

Embed the AKI pathway and improve compliance Staff education – on-going rolling program Alert system to be initiated to ensure that AKI is automatically flagged

Progress during 2013-2014: Development of an AKI pathway. A pathway has been developed from the London AKI network pathway. This includes a care bundle checklist to enable the early recognition and treatment of AKI. The bundle also includes the complications of AKI and the appropriate medical interventions and management options for this. A base line audit was conducted which identified some good areas of practice; prompt checking of blood tests on arrival in ED, fluid boluses, more complex blood tests to look for aetiology of renal failure and management of complications such as hyperkalaemia.

The audit also identified the following areas for improvement; urinalysis, fluid balance recording, arranging prompt renal tract ultra sound, clarity in medical notes about the likely cause for AKI, involvement of renal physicians, and medication review (stopping nephrotoxins).

Following the audit an education programme was introduced (see below) together with visual prompts and a clinical management guideline. A further audit was completed six months later which demonstrated some improvements in medication reviews, fluid balance recording, and a small improvement in urinalysis. There are on-going concerns about:

o recognition of AKI (particularly in patients with a daily modest rise in creatinine which amounts to a significant rise over a few days),

o prompt renal ultrasound, and o involvement of renal physicians.

Development of medical staff training: A training programme for the junior doctors has been in progress, facilitated by one of the lead patient safety clinicians. An AKI scenario has been incorporated into simulation training for junior doctors. It is a top 20 teaching subject (twice yearly) and has been the subject of the bi-monthly Medical Directors briefing to trainees on two occasions. Identity badge sized prompt cards have been developed and poster reminders about the AKI management checklist are displayed on every ward.

Development of nursing staff training on the recognition of AKI and appropriate monitoring: The AKI pathway was launched at the nursing skills blitz day in November 2013. The management and treatment of the AKI patient has been included in patient safety training for all registered nurses and developed around a patient scenario. AKI training has also been incorporated into Alert training. The preceptorship training programme for nurses includes a session on AKI and the student nurses also undertake an AKI training session. Training for unregistered staff has been delivered via the care assistant induction program and the Bedside Emergency Assessment Course for Health Care Assistant’s (BEACHES) training.

The Trust intends that the AKI steering group will monitor compliance with the AKI pathway, staff education programme, and implementation of the pathology system (AKI flag) in order to highlight progressive modest increases in creatinine.

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Hospital acquired methicillin-resistant staphylococcus aureus (MRSA) and clostridium difficile (C. diff) MRSA is a common skin bacterium which has become resistant to some of the more widely used antibiotics. C.diff is a major cause of antibiotic-associated diarrhoea and colitis (an infection of the intestine).

Rationale for inclusion: To reduce further the rates of infection and therefore improve patient safety.

Both MRSA and C.Diff are governed by national definitions.

The Trust has made significant improvements over several years in reducing the number of healthcare-associated infections over several years. This year we reported four MRSA bacteraemias. Full root cause analysis was conducted on each case to identify whether the case could have been avoided. The root cause meetings reported that only one case was avoidable.

Total number of MRSA Bacteraemia cases MRSA Bacteraemia cases reported as ‘avoidable’ or ‘unavoidable’

Source: Trust data, March 2014

We have further reduced our low rates of C.diff, with 15 reported cases. These results mean that we remain one of the best performing trusts regionally and nationally for C.diff.


Data shown differs from that reported in 2012-2013 as community results were included in reporting until 2010. Data now reflects hospital-attributed CDI cases only.

6

3

2

1

4

0

1

2

3

4

5

6

7

8

9

10

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

Nu

mb

er

of

ho

spit

al-

att

rib

ute

d M

RS

AB

ca

ses

MRSA Bacteraemia

1 1

0 0

1

5

2 2

1

3

0

1

2

3

4

5

6

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

Nu

mb

er

of

ho

spit

al-

att

rib

ute

d M

RS

AB

ca

ses

MRSA Bacteraemia

Avoidable

Unavoidable

356

167

84

21 15 16 15

0

50

100

150

200

250

300

350

400

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14

Clostridium Difficile

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Hospital acquired pressure ulcers – grades 2, 3 & 4 A pressure ulcer (also known as a pressure sore or bed sore) is an ulcerated area of skin caused by irritation and continuous pressure on part of the body. Pressure ulcers are categorised in four grades which are linked to severity. Patches of discoloured skin are categorised as a grade 1 and the most severe grade is 4. They are more likely to occur in people who are under or overweight, have a poor nutritional status and/or poor vascular function.

Rationale for inclusion: It is our intention to reduce preventable harm by a further 15% (average) by the end of the three year Quality Strategy 2013-2016 in order to realise our ambition to become the safest NHS hospital nationally. In 2013-2014 the Commissioning for Quality and Innovation (CQUIN) payment framework made a proportion of our income conditional on a pressure ulcer reduction. Hospital acquired pressure ulcers are one of the indicators selected for inclusion as an aggregate harm reduction measure.

Pressure ulcer data is governed by standard national definitions.

The table below sets out our performance over the last six years. It is evident from the data that a significant reduction was achieved during 2013-2014 when compared with the previous year. The Trust has continued the excellent results in grade 4 pressure ulcers and has again reported no grade four pressure ulcers this year.

Indicator % Reduction (2009–2012)

Baseline (2012-2013 outturn)

2013-2014 % Reduction

from baseline

Trend over time

Hospital acquired pressure ulcer grade 2

8% 144 88 39%

Hospital acquired pressure ulcer grade 3

75% 15 7 53%

Hospital Acquired pressure ulcer grade 4

100% 0 0 Zero tolerance Improvement

maintained Source: Trust data, April 2013 - February 2014

Since 2008-2009 the Trust has reduced the number of hospital acquired pressure ulcers by 241 (72%). This year the Trust has further reduced the number of pressure ulcers by 64 (40%) from the previous year (2012-2013).

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Falls resulting in significant injury by overall activity

A fall is an unintentional loss of balance causing an unexpected collapse. Falls can result in significant harm such as severe head injury or broken bones.

Rationale for inclusion: It is our intention to reduce preventable harm by a further 15% (average) by the end of the three year Quality Strategy 2013-2016 in order to realise our ambition to become the safest NHS hospital nationally. Our aim this year was to maintain the percentage against activity of falls resulting in significant harm at 0.03%.

‘Falls resulting in significant harm’ data is governed by standard national definitions.

Indicator 2010-2011 2011-2012 2012-2013 2013-2014 Trend over

Time* % falls resulting in significant injury by overall activity

0.10% 0.08% 0.03% 0.03%

Source: Trust incident data, March2014 *Trend over time relates to 2010-2011 data

The table above demonstrates performance against activity over the last four years. In 2013-2014 the Trust maintained the improvement made during 2012-2013 in reducing the proportion of falls resulting in significant injury despite a rise in activity.

Venous Thromboembolism

Venous thromboembolism (VTE) is a condition in which a blood clot (thrombus) forms in a vein/blood vessel which can lead to pain and swelling. If the blood clot becomes dislodged it can travel in the bloodstream (embolism) and it can potentially block vital arteries which can be fatal. When the embolism blocks a vital artery to the lung it is called a pulmonary embolism (PE).

Rationale for inclusion: VTE was identified as a top clinical priority for the NHS in the 2011-2012 operating framework. In 2011-2012 and 2013-2014 the Commissioning for Quality and Innovation (CQUIN) payment framework made a proportion of our income conditional on a VTE-related requirement which is also supported by the NICE quality standard.

The VTE risk assessment data is governed by standard national definitions.

The aim for 2013-2014 was to assess at least 96% of patients for their VTE risk in every month of the year. We exceeded this target in every month.


Time*


Source: Trust data, February 2014 *Trend over time relates to 2010-2011 data

The table above demonstrates that the Trust performance this year has seen a significant improvement over the previous year.

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NHS Safety Thermometer - % harm free care

The NHS Safety Thermometer (NHS-ST) is an improvement tool for measuring, monitoring, and analysing patient harm and harm free care for VTE, pressure ulcers, falls and urinary catheter associated infection.

Rationale for inclusion: to further reduce the instance of harm to our patients.

The NHS ST is governed by national standardised definitions.

The aim for this year was to achieve at least 95% harm free care using the NHS ST measurement tool.


Time*

NHS ST % harm free N/A N/A 93% 95%

Source; Trust incident data March 2014 *Trend over time relates to 2012-2013 data

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Clinical Outcomes

Our newly commissioned information system package, Hospital Episode Database (HED), allows us to compare our specialty clinical outcomes nationally to identify areas where there is room for improvement.

Transient Ischaemic Attack & Stroke

A transient ischaemic attack (TIA) or 'mini-stroke' is caused by a temporary disruption in the blood supply to part of the brain. The disruption in blood supply results in a lack of oxygen to the brain.This can cause symptoms similar to those of a stroke, such as speech and visual disturbance and numbness or weakness in the arms and legs. However, unlike a stroke, the effects only last for a few minutes and are resolved within 24 hours.

Rationale for inclusion: TIA and stroke have been a key focus and priority for the Trust since 2009. Since then vast improvements to our TIA and stroke services have been made and an Early Supportive Discharge Team programme has been introduced. In our drive for excellence and continued improvement to both services, we are continuing to focus on achieving the national targets.

The data is governed by standard national definitions.

We will specifically focus on achieving the national and local stretch targets for the indicators set out in the results table:

Indicator 2011-2012 2012-2013 2013-2014 Performance against target

80% of patients spend 90% of their inpatient episode on the stroke unit (new 2013/14)

New New 89%

50% of [all] patients receive brain imaging within one hour of arrival *

31% 45% 54%

60% of eligible patients receiving thrombolysis <60 minutes of arrival (door to needle)

56% 49% 66%

90% of patients receiving brain imaging within 12 hours of arrival (new 2013/14)

New New 96%

95% of patients receiving a swallow screen within four hours of admission to stroke team

New 95% 98%

90% of direct admission to acute stroke unit within four hours of arrival

New 72% 83%

40% of patients discharged under the Early Supported Discharge (ESD) team

35% 36% 36%

70% high risk TIA patients treated < 24 hours of 1st contact

59% 75% 78%

Source; Trust data, March 2014

*Indicator reflects Royal College of Physicians (RCP) Guidelines for Stroke for measuring imaging performance for all patients scanned within one hour and replaces the indicator “80% of patients [eligible for immediate brain] receive brain imaging within one hour of arrival”.

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Vascular (Abdominal Aortic Aneurysm)

An abdominal aortic aneurysm (AAA) is a bulge in the largest blood vessel in the body caused by a weakness in the blood vessel wall. As blood passes through the weakened blood vessel, the blood pressure causes it to bulge outwards like a balloon.

Endovascular aneurysm repair (EVAR) is surgery to repair an aneurysm in the aorta.

Rationale for inclusion: The vascular team continued to see an increase in activity this year and performed a total of 77 AAA procedures to November 2013 compared with 71 at the same time last year. In last year’s report we changed the quality indicators to be reported from 2013-2014 (see list below). The rationale for this change was to align with the National Vascular Database and to drive improvement to our services.

number of aneurysm repairs undertaken split between elective and emergency procedures

number of aneurysm repairs undertaken as an open or EVAR procedure (2012/13 102)

30 day mortality for all aneurysm repairs (new)

number of carotid endarterectomy procedures performed (new)

number of carotids performed within 14 days of onset of symptoms

Carotid 30 day mortality and stroke rate (new)

All vascular performance data will be presented in November of each year to coincide with National Vascular Database data collection completion and report publication.

Vascular (Abdominal Aortic Aneurysm) 2012-2013 2013-2014

Number of emergency abdominal aortic aneurysm (AAA) performed* 32 16

Number of elective abdominal aortic aneurysm (AAA) performed* 70 61

Number of AAA repairs undertaken as EVAR procedure* New 48

Number of AAA repairs undertaken as open procedure* 47 29

30 day mortality for all aneurysm repairs New 5

Number of carotid endarterectomies (CEA) performed* New 42

% of CEA performed < 2 weeks of symptomatic onset* 100% 94%

Mortality index CEA New 0

CEA stroke rate New 1

*Data linked to national audit collection Source: Trust data, December 2013

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Acute Myocardial Infarction Myocardial Infarction (MI) is commonly known as a heart attack and it happens when a part of the heart muscle suddenly loses its blood supply usually due to a blood clot.

An electrocardiogram (ECG) records the electrical activity of the heart. The heart produces tiny electrical impulses which spread through the heart muscle to make the heart contract. These impulses can be detected by the ECG machine. An ECG is performed to help find the cause of symptoms such as palpitations or chest pain.

Percutaneous coronary intervention (PCI) is a non-surgical procedure used to treat narrowing of the coronary artery, using a balloon catheter to dilate (widen) the artery from within.

Rationale for inclusion: As cardiac intervention services form part of the Trust’s hyper-acute strategy, the Trust will continue to focus on improving performance. We said in last year’s Quality Report that the focus will be on the achieving the following standards:

85% of eligible patients receive treatment, call to balloon within 150 minutes (new)

85% of eligible patients receive treatment, door to balloon within 60 minutes

85% of eligible patients have an ECG performed within 15 minutes of arrival (new)

30% of eligible patients receive a PCI as a day case

40% of eligible patients receive a pacemaker as a day case

The Trust introduced reporting on cardiology standards in the 2010 Quality Report and we have made significant improvements since then. We have recruited additional consultants, opened our cardiac centre and opened a second catheterisation laboratory. We have also been recognised by our local commissioners (Surrey and Hampshire) as the key provider of primary PCI services.

Data is governed by standard national definitions.

Indicator 2011-2012 2012-2013 2013-2014 Achievement against target

85% of eligible patients receive treatment; call to balloon within 150 minutes

90% 91% 91%*

85% of eligible patients receive treatment; door to balloon within 60 minutes

79% 86% 87%*

85% of eligible patients have an ECG performed within 15 minutes of arrival

95% 97% 97%*

30% of eligible patients receive a PCI as a day case 24% 51%**

40% of eligible patients receive a pacemaker as a day case.

39% 49%**

Source: *MINAP March 2014 ** Trust Performance data March 2014

49

Trauma Services Trauma services look after patients who have serious and complex injuries that could potentially result in death or serious disability.

Rationale for inclusion: Because the Trust offers a wider range of specialist services, we are now keeping/attracting patients who previously would have gone to other centres eg spinal, large trauma and orthopaedic injuries, and vascular patients. The Emergency Department believes that our trauma activity is increasing due to the Trust’s programme of increasing emergency department consultant led services, travel time to the nearest major trauma centres and ambulance service confidence. However, this is difficult to confirm as a large proportion of national Trauma Audit and Research Network activity does not result in a ‘trauma call’ and is therefore ineligible for TARN data submission. By continuing to refine the data collection and patient identification process, and measurement of Trust performance nationally, patient’s outcomes will continue to improve.

The performance against TARN indicators is governed by standard national definitions and is a continuous process. The Trust has built a good profile for TARN participation (see table below).

Hospital Name Completeness of Data 2011

Completeness of Data 2012

Completeness of Data 2013

Frimley Park NHS Foundation Trust 65.9% 87.7% 104.2%* Source; TARN website, February 2013

*Submission percentage is based on the previous year’s TARN submissions and historic Hospital Expected Statistics (HES) and therefore over/under submission rates are expected. With the implementation of the electronic patient record system (Symphony), the Trust is identifying patients who have not been identified by HES and this has further increased our submission rates.

To ensure that we enhance the quality of our trauma services we will monitor the following standards in 2014-2015 and aim to ensure that:

80% of trauma teams are led by an ED or other appropriate consultant

Analgesia is provided to patients within 15 minutes of arrival (trauma calls). New.

80% of patients with a head injury will receive a CT scan within 60 minutes of arrival.

80% of time critical transfers are completed within one hour. New.

100% of trauma calls and trauma deaths are reviewed at Mortality & Morbidity meetings. New.

90% of open fractures receive antibiotics within one hour of arrival to the Emergency Department. New.

50

Trauma (TARN) performance April to December 2013.

Indicator 2012/13 2013/14 Achievement against target

80% of trauma teams are led by an ED or other appropriate consultant

New 79%

Analgesia is provided to 90% patients within 15 minutes of arrival (trauma calls)(new)

New 100%

80% of patients with a head injury will receive a CT scan within 60 minutes of arrival

76% 86%

80% of time critical transfers are completed within one hour (new)*

New 33%

100% of trauma calls and trauma deaths are reviewed at Mortality & Morbidity meetings (new)

New 100%

90% of open fractures receive antibiotics within one hour of arrival to the department (new)

New 78%

Source: TARN data Quarter 3 Note that the data for the above indicators is linked to audit and will be reported in arrears. Quarter 3 data is likely to improve further

as additional patients are identified by HES.

*Reflective of quarter 1 data only. There were no eligible patients in quarters 2 or 3.

51

Dementia

Dementia is a syndrome (a group of related symptoms) associated with an ongoing decline of the brain and its abilities. This includes problems with; memory loss, thinking speed, mental agility, language, understanding and judgement.

Rationale for inclusion: One in three people over 65 will have some form of dementia. 670,000 people in England are living with dementia (predicted to double in the next 30 years – Department of Health 2012). Identified by the Trust (and noted by the CQC in the last inspection report) as a priority area for improvement. The indicators in the table below were monitored as part of the Trust’s CQUIN scheme during 2013-2014 and are not governed by standard national definitions:

Indicator 2012/13 2013/14 Achievement against target

100% compliance with the training schedule New 100%

90% of all admitted patients (75+) who have been screened for Dementia (within 72 hours)

93% 100%

90% of all admitted patients (75+) who scored positively on the dementia screening tool that then received a dementia diagnostic assessment (within 72 hours)

91% 100%

90% of all admitted patients (75+) who received a dementia diagnostic assessment with a ‘positive’ or ‘inconclusive’ outcome that were then referred for further diagnostic advice/follow up (within 72 hours).

85% 100%

Source: Trust data March 2014

It is recognised that people with dementia do not respond well to changes in environment and their routine. The Trust is keen to provide an excellent service and we have therefore introduced a questionnaire which can be completed by the carer/relative of patients with dementia in order to better understand what carers think of their experience.

Indicator 2013-2014

Percentage of patient carers who would recommend our services to friends and family (likely & extremely likely). New.

89%

Percentage of patient carers who would score the care received by their relative/friend between 6 – 10 (higher better). New.

89%

Source: Trust data, Meridian Carers Survey, March 2014

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Patient Experience

The experience of our patients is as important as their health outcomes and is central to our mission to provide the highest quality care. This is the main rationale for the work we do.

During 2013-2014 the Trust has continued to collect real time feedback on a wide range of quality indicators. A total of 7,127 patients and their relatives or carers participated in our local inpatient survey and a total of 25,010 inpatients, maternity users, and those attending A&E participated in the national Friends and Family Test (FFT).

The last Quality Report (2012-2013) defined the following priorities for this reporting year: 1. Essential care needs.

2. Patient experience in the ED. 3. Patient experience of maternity services. 4. Carer/relative experience for patients with a diagnosis of dementia. 5. National Family and Friends Test.

Rationale for inclusion: To improve the standards of care and the experience our patients receive.

Essential care needs:

There are many essential standards of care. We consider that the following three ‘needs’ are a crucial and a basic part of patient care in our hospital. We will, therefore continue to monitor and improve our performance against the indicators below.

Indicator 2012

(National Survey)

2013-2014 Trend over

time*

95% of inpatients report they are always treated with dignity and respect. New. 83% 97%

95% of inpatients report that they were given enough privacy when discussing their treatment/condition. New.

73% 93%

95% of inpatients report that they receive the required assistance with washing/dressing, eating/drinking and mobilising. New

- 92% N/A

95% of inpatients who would definitely recommend the Trust - 95% N/A

Source: Trust local survey data (Meridian), March2014 Trend over time relates to the 2012 CQC National Survey results

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The Trust collects real-time feedback from patients using local patient satisfaction surveys (Meridian) and the national Friends and Family Test. The tables below show the local Meridian survey results.

Patient experience in the Emergency Department (ED)

The local survey demonstrates that the ED is performing well against the indicators below. However, since the introduction of the national FFT, it is challenging to also obtain feedback from patients for the local survey. The number of participants is therefore lower than expected at 484.

Indicator 2013-2014

Patients who rate the care/treatment received as good/very good/excellent*

93%

Patients who were definitely/to some extent involved as much as they wanted in decisions about their treatment/care*.

95%

Source: *Trust data, Meridian Survey, March 2014

Patient experience of Maternity services

The local Maternity service is performing well against the indicators below. However, since the introduction of the national FFT, it has proven challenging to also obtain feedback from patients for the local survey. The number of participants is therefore lower than expected at 159 and 469 respectively.

Indicator 2013/14

Patients who rate the care/treatment received as good/very good/excellent. New.*

98%

Patients who were definitely/to some extent involved as much as they wanted in decisions about their treatment/care. Antenatal/labour and birth. New.**

99%

*Source: Trust data, local Meridian Maternity survey, March 2014 **Source: Trust data, local Meridian Maternity Inpatient survey, March 2014

Carer/relative experience for patients with a diagnosis of dementia

Engaging carers to provide local survey feedback has been challenging. The number of participants is disappointing at 19 but we will aim to increase this number in the coming year as well as exploring other methods of obtaining feedback on the dementia service.

Indicator 2013/14

Percentage of patient carers who would recommend our services to friends and family.

89%

Percentage of patient carers who would rate/score the care received by their relative/friend as good, very good or excellent. (Score of 10 – 7, higher is better)

89%

Source: Trust local survey data, March2014

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National Friends and Family Test

Rationale for inclusion: The DH has introduced a new measure for patient experience as part of healthcare providers’ contracts. The new measure is called the Family and Friends Test (FFT) and it requires healthcare providers to ensure that patients with an overnight stay and those who attend the emergency department are asked: “How likely are you to recommend our ward/Accident and Emergency department to friends and family if they needed similar care or treatment”. There are six response categories: extremely likely, likely, neither likely nor unlikely, unlikely, very unlikely or don’t know.

First phase: inpatients (ward) and Accident and Emergency

The Trust has fully embraced and embedded the FFT which is reflected in the exceptional performance compared with the national average. Data is governed by standard national definitions.

Response rate is calculated using the number of inpatients (who were admitted for at least one night) or the number of Accident and Emergency department attenders compared with the number of responses received.

Indicator 2013-2014 Target

2013-2014 Performanceagainst target

Accident and Emergency department response rate. New. 24% 20%

Inpatient (ward) response rate. New. 37% 20%

Combined Inpatient and Accident and Emergency department response rate. New.

28% 20%

Source: Trust data, March2014

The FFT NPS is calculated by the proportion of people who responded extremely likely minus the proportion of people who responded in the neither likely nor unlikely, unlikely or very unlikely categories. This number is then shown as a score. The range of possible scores is -100 to +100. A score of +50 is considered to be excellent.

Trust FFT national promoter score (NPS): local and national comparison: Inpatients Accident & Emergency

Red line = Trust data Blue Line = National average comparison data Pink Line = Local area average comparison data

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Proportion of FFT inpatient negative responses: The responses classed as negative is: neither likely nor unlikely, unlikely and extremely unlikely.

Inpatients Accident and Emergency

Source: NHS England, FFT Analysis Site, February 2014


Second phase: Maternity services

Rationale for inclusion: to establish the level of satisfaction with our maternity services with the aim of improving women’s experience.

Indicator 2013-2014

FFT Response rate: Antenatal Services (new): In Hospital Community

18% 29%

FFT Response rate (new): Birth In HospitalCommunity

36% 32%

FFT Response rate (new): Post Natal Care In Hospital Community

52% 37%

Indicator 2013-2014 Target

2013-2014 Performance against target

FFT Net Promoter Score: Antenatal Services (new): In Hospital Community

87 82 50

FFT Net Promoter Score (new): Birth In Hospital Community

87 79 50

FFT Net Promoter Score (new): Post Natal Care In HospitalCommunity

79 89 50


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FFT proportion of negative responses: local and national comparison: Antenatal Birth

Postnatal Ward Postnatal Community

Source: NHS England, FFT Analysis Site, February 2014


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Part 3: 3.2 Frimley Park Hospital NHS Foundation Trust performance against selected

Monitor metrics 2013-2014

Monitor is the health sector regulator. As part of this work Monitor sets the Trust guidance on some of the reporting requirements in this report. These requirements are partly set out in the table below:

Indicator Monitor

Threshold FPH

Performance against

threshold Clostridium Difficile (C. diff) – meeting the C. diff objective.

(Number of avoidable cases)(The year end position for the indicator above has been audited by PwC)

8 15* (5)

All cancers: 31-day wait for second or subsequent treatment comprising either:

– Surgery – Anti cancer drug treatments

– Radiotherapy

94% 98% 94%

100% 100% 100%

All cancers: 62-day wait for first treatment, comprising either: – Urgent GP referral for suspected cancer

– NHS cancer screening service referral(The year end position for the indicator above has been audited by PwC)

85% 90%

89% 97%

Maximum time of 18 weeks from point of referral to treatment in aggregate

- admitted- non-admitted

- Incomplete pathways

90% 95% 92%

Apr – Jan

93.1% 97.7% 95.4%

All cancers: 31-day wait from diagnosis to first treatment 96% 99%

Cancer: two week wait from referral to date first seen, comprising either:

– All urgent referrals (cancer suspected)– For symptomatic breast patients (cancer not initially

suspected)

93% 93%

95% 97%

ED -maximum waiting time of four hours from arrival to admission/transfer/discharge

95% 95.54%

Certification against compliance with requirements regarding access to healthcare for people with a learning disability healthcare for people with a learning disability

NA NA -

Cancer data covers Apr13-Feb14 RTT data covers Apr13-Feb14

*The Trust has reduced the number of C.diff cases from 16 in 2012-2013 to 15 during 2013-2014

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Annex I Statements from the Council of Governors, OSC and Commissioners Patient Experience and Involvement Group (PEIG) comments on Quality Report 2013/14 A sub-group of the PEIG has reviewed the 2014 Quality Report. As a sub-group of the Council of Governors (the Governors) the PEIG comprises publicly elected Governors, Staff Governors, Stakeholder Governors and co-opted members with relevant patient expertise and experience. As such the group is in an ideal position to monitor the quality of service at Frimley Park Hospital NHS Foundation Trust (the Trust). The PEIG has sought to evaluate on going quality at the Trust throughout the year focusing on two key areas namely:

- is the patient experience excellent in all aspects? - are procedures and practices geared to ensuring the safety and wellbeing of the patients?

The PEIG has been assured that quality standards underpin the performance of the Trust and that in addition national standards have been adhered to by the Trust. Additionally PEIG members have worked closely with the Care Quality Commission (CQC) Engagement Project to ensure quality standards remain at the forefront of the Trust’s thinking and activities. The sub-group of the PEIG feels that the Report accurately defines the quality standards, the targets, the achievements and the hospital’s determination to continue to strive for on-going improvements. Indeed the award of Hospital of the Year – South of England by Dr Foster in December 2013, following the achievement last year of Trust of the Year Runner Up, provides strong evidence that the quality approach to service provision at the Trust is paying dividends. Further evidence of the strong leadership of the Trust was seen in February 2014 when the Board won national Board/Governing Body of the Year at the National NHS Leadership Recognition Awards 2014. Other highly commendable achievements include the overwhelmingly positive Care Quality Commission (CQC) report received following the most rigorous inspection the Trust has ever undergone, and confirmation from the national staff survey results and the CQC that our staff are happy working for the Trust and demonstrate passion about caring for our patients, their families, and carers. The group also felt strongly that engaged, well supported, staff impact positively on the care and outcomes of patients and therefore fully supports the development of the Ward Leadership Programme. 22 senior sisters embarked on the programme over nine months, finishing in the summer of 2014. The programme’s aim is to equip these key staff with the skills and confidence necessary for them to take ownership of their clinical areas and drive forward all aspects of quality care. The PEIG is fully supportive of the priorities for improvement identified for 2014-2015 i.e. improving the recognition and management of patients with an acute kidney injury (AKI), reducing the instance of catheter associated urinary tract infection, and improving the number of patients with sepsis who receive antibiotics within one hour. The group was pleased to see the progress made this year, however, there is clearly some way to go to fully embed the associated pathways and treatment protocols. The PEIG will continue to monitor performance against these priorities next year. Following the Francis Report and subsequent Keogh Mortality Review, the Trust undertook a review of staffing levels and has made significant investments to ensure that staffing ratios reflect patient acuity. The Quality Report details the actions the Trust has taken against each of the Keogh ambitions. The PEIG has gained significant assurance on how our patients feel about the care they receive from the national Friends and Family Test introduced this year. The Trust has consistently achieved higher response rates than other local Trusts since the test was introduced in April 2013 and has achieved response rates in the upper quartile nationally. The PEIG therefore, has a high degree of confidence in the excellent net promoter score (NPS).

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At a more detailed level the PEIG is kept well briefed and aware of all quality targets and performance against them. The group is involved in the review of quality priorities and is assured that quality issues are taken very seriously by FPH staff. Along with other Governors, PEIG members are involved in the Quality Assurance Walkabout programme where we see first-hand how the doctors, ward sisters, nurses and other clinical support professionals such as occupational therapists and physiotherapists interact with patients and their families and carers. Such close involvement enables Governors to really get a “feel” for how FPH is operating and enables the highlighting of areas requiring attention or improvement. As in last year’s report, the achievement against specific targets that the report contains is best viewed from the perspective of trends. It is reassuring to note that there has been on-going and excellent commitment to reduce cases of MRSA and C.Diff despite very challenging targets. Although the Trust has seen 4 cases of MRSA, the PEIG is pleased to note the actions taken by the Infection Control team and Microbiologists following an in-depth review of each case, resulting in a review of the Trust antibiotic prescribing policy currently being ratified by the relevant committees. The group was pleased to note that there has been significant progress made in the TIA and stoke services, particularly the timing of admission and administration of thrombolysis as this was a focus for improvement from last year. We were delighted to note that the Trust has maintained zero cases of grade 4 hospital acquired pressure ulcers (PUs) and further improved the number of grade 2 and 3 PUs. In conclusion the group is satisfied that the Report is a true statement of quality at the Trust and is assured by the significant achievements detailed in part 1 of the Quality Report that there is strong evidence that both managers and staff are not complacent and continue to push the boundaries of quality for patients, their families, and carers to excellent effect. Nicky Dodsworth Keith Dingle Lead Governor Chairman, PEIG 30 April 2014 30 April 2014

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North East Hampshire and Farnham, Surrey Heath and Bracknell and Ascot Clinical Commissioning Groups response to the Frimley Park Hospital NHS Foundation Trust Quality Account 2013/14 North East Hampshire and Farnham (NEHF), Surrey Heath (SH) and Bracknell and Ascot (BaA) Clinical Commissioning Groups have reviewed Frimley Park Hospital NHS Foundation Trust’s Quality Account. The Quality Account provides information on the performance of the Trust against quality improvement priorities for the year 2013-14 using a wide range of internal and external quality measures, to give an overview of the quality of care provided by the Trust. The priorities and ambitions for improvement are also set out for the next 12 months. The Clinical Commissioning Groups (CCGs) are satisfied as to the accuracy of the data contained in the Account. The CCGs welcomed the outcome of the Care Quality Commission (CQC) inspection undertaken in November 2013 where the Trust was judged to be providing services that were safe and effective across all key areas. There was a clear strategy and a consistent and stable approach with caring and compassionate staff. During 2013/14 the Trust has also sustained high levels of patient satisfaction and been awarded external recognition from Dr Foster on mortality and safety and the National Leadership Academy for Trust Board of the year. The CCGs commend these achievements and acknowledge the strong and effective leadership of the organisation. During 2013/14, the Trust has actively engaged with stakeholders and partners as the health and social care work together to transform services to optimise quality and efficiency across a complex geographical area. The CCGs and the Trust continue to work closely through the monthly Clinical Quality Review Group meetings. During 2013/14, focus has been maintained on maternity, stroke, A&E, Venous Thromboembolism, falls, hospital re-admissions and Hospital Acquired infections. Progress in all areas will continue to be monitored during 2014/15. It is acknowledged that seven day working further enhances consultant delivered services ensuring patients receive the highest possible standard of care. The recently opened Surrey Heart, Stroke and Vascular Centre will also further enhance patient outcomes. The CCGs acknowledge that the Trust have plans to further improve the care for patients with dementia and improve the environment for patients and their carer’s. The report identifies the Trust’s achievements to date, and also areas within their service delivery that require further improvement. The CCGs will continue to support the Trust in achieving improvement in those areas identified within the Quality Account through existing contract mechanisms and collaborative working. Throughout 2013/14 there has been a number of serious incidents reported relating to patient falls resulting in serious harm. The CCGs are pleased to note that this is a priority for continued focus by the Trust with a strong commitment to continually improve patient safety across the healthcare system. In addition the CCGs note the on-going commitment to monitoring patient harm through the NHS Safety Thermometer and the aim to reduce falls during 2014/15 by 10%. The Trust has demonstrated a significant reduction in pressure ulcers during 2013/14. The CCGs note that the number of hospital acquired Methicillin-Resistant Staphylococcus Aureus Bacteraemia (MRSAB) cases have increased from one in 2012/13 to four in 2013/14. Following in-depth reviews one of these four was deemed avoidable which has breached the zero tolerance threshold. It is acknowledged that the Trust has identified and implemented learning points related to this case. The Trust worked hard to try to achieve the Clostridium Difficile target of 8 for 2013/14. However it is noted that this target was breached by seven cases. The CCGs are aware of the challenge that the Trust faced during 2013/14 to achieve the target of eight cases and acknowledge that overall the number has reduced by one from 16 in 2012/13 to 15 in 2013/14.

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The Trust has one of the highest response rates for the Friends and Family Test in the country within the Accident & Emergency Department with 94% of respondents being ‘extremely likely’ or ‘likely’ to recommend those services to friends and family. The maternity Friends and Family Test, show that 99% of respondents would be ‘extremely likely’ or ‘likely’ to recommend those services. It is noted that the Trust are working towards improvement across a wide range of quality indicators related to patient experience including those from the local in-patient survey. This Quality Account provides a comprehensive overview of the quality of care within the Trust and the priorities for 2014/15 align with the strong focus on quality by the CCGs. We look forward to continuing to work alongside the Trust in meeting the quality aspirations of patients, carers, members of the public, stakeholders, partners and staff.

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Surrey Health Scrutiny Committee (including Healthwatch) responses to the Frimley Park Hospital NHS Foundation Trust Quality Report 2013-2014

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Response to the Frimley Park Hospital NHS Foundation Trust Quality Report 2013-2014 from Bracknell Forest Healthwatch, on behalf of Bracknell Forest Oversight and Scrutiny Committee and Healthwatch. Quality Account Statement Frimley Park Hospital NHS Trust Healthwatch Bracknell Forest collects both positive and negative feedback/concerns from their population. The compliments we have received about the Trust are centred around clinical services. Concerns or areas for improvement have mainly centred around car parking and transport back to Bracknell Forest if discharged from Accident and Emergency or a ward after 8pm. We also receive the National Inpatient Survey data as well as well as sitting on East Berkshire’s quality committee. Healthwatch Bracknell Forest would comment that the Trust, whilst having high scores on the Friends and Family test, scored low on patient feedback and information on how to make a complaint in the National Inpatient Survey. Healthwatch Bracknell Forest would ask the Trust to make these areas of patient experience priorities in 2014/15. Healthwatch Bracknell Forest will work with the Trust, where appropriate, to improve the patient experience and pathway through the hospital system. Healthwatch Bracknell Forest will also during the year continue to monitor stroke care as this has been highlighted as a potential area of concern and also how internal enquiries are conducted. If the proposed acquisition of a neighbouring Foundation Trust is successful, Healthwatch Bracknell Forest would like to see the neighbouring Trust’s role of Associate Director for Patient Experience and Public involvement maintained and expanded across all Trust sites to meaningfully engage with patients and the public.

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Annex II

Statement of Directors’ responsibilities for the Quality Report

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 incorporates the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support data quality for the preparation of the quality report.

In preparing the quality report, directors are required to satisfy themselves that:

The content of the quality report meets the requirements set out in the NHS foundation trusts annual reporting manual 2013-2014.

The content of the quality report is not inconsistent with internal and external sources of information included:

o Board minutes and papers for the period April 2013 to May 2014. o Papers related to quality reported to the Board over the period April 2013 to May 2014. o Feedback from commissioners North East Hampshire and Farnham, Surrey Heath and

Bracknell and Ascot CCGs dated 16 May 2014. o Feedback from Patient Experience and Involvement Group on behalf of the governors dated

30 April 2014. o Feedback from Surrey Health Scrutiny Committee (including Healthwatch) dated 21 May 2014. o The Trust’s complaints report published under regulation 18 of the Local Authority Social

Services and NHS Complaints Regulations 2009 dated July 2013. o Latest national patient survey 2013. o Latest national staff survey 2013. o Care Quality Commission quality and risk profiles dated April 2013, June 2013, July 2013,

August 2013 o Intelligent Monitoring Reports dated October 2013 and March 2014. o The Head of Internal Audit’s annual opinion over the Trusts control environment dated March

2014.

The Quality Report presents a balanced picture of the NHS Foundation Trust’s performance over the period covered.

The performance information in the quality report is reliable and accurate.

There are proper internal controls over the collection and reporting of the measures of performance included in the quality report, and these controls are subject to review to confirm that they are working effectively in practice.

The data underpinning the measures of performance in the Quality Report is robust and reliable, confirms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and,

the quality report has been prepared in accordance with Monitor’s Annual Reporting Guidance (which incorporates the Quality Accounts Regulations) (published at www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data quality the preparation of the quality report (available at www.monitor.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=3275).

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

By order of the Board

Sir Mike Aaronson Andrew Morris Chairman Chief Executive 22 May 2014 22 May 2014

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Annex III Glossary Abbreviation Description Good performance Decreased performance AAA Abdominal Aortic Aneurysm ASU Acute Stroke Unit A&E Accident and Emergency CCG Clinical Commissioning Group C.Diff Clostridium Difficile

CAUTI Catheter Associated Urinary Tract Infection

CHKS A provider of healthcare intelligence and quality improvement services

CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation –incentive scheme

DH Department of Health ED Emergency Department FFT Friends and Family Test FPH Frimley Park Hospital NHS GTT Global Trigger Tool HA Hospital Acquired/Associated

HSMR Hospital Standardised Mortality Ratio

Abbreviation Description MI Myocardial Infarction

MINAP Myocardial Ischaemia National Audit Project

MRSA Methicillin Resistant Staphylococcus Aureus

NHS National Health Service

NICE National Institute of Health and Clinical Excellence

NPSA National Patient Safety Agency PE Pulmonary Embolism

PCI Percutaneous Coronary Intervention

PCT Primary Care Trust

PEAT Patient Environment Action Team

PROMs Patient Reported Outcome Measures

RCA Root Cause Analysis

SHMI Standardised Hospital Mortality Index

SIRI Serious Incident Requiring Investigation

TARN Trauma Audit and Research Network

VAP Ventilator Associated Pneumonia

VSQIF Vascular Society Quality Improvement Framework

VTE Venous Thromboembolism

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Annex IV External Quality Definitions The following information includes the definitions of the quality indicators which were subject to the external assurance process. Clostridium Difficile (C. Difficile) Indicator descriptor: number of Clostridium Difficile infections (see definition) for patients aged 2 or more on the date the specimen was taken Data definition: A C. Difficile is defined as a case where the patient shows clinical symptoms of C. Difficile infection and using the local Trust C. Difficile infections diagnostic algorithm (in line with DH guidance) is assessed as a positive case. Positive diagnosis on the same patient more than 28 days apart should be reported as separate infections, irrespective of the number of specimens taken in the intervening period, or where they were taken. Accountability: acute provider trusts are accountable for all C. Difficile infection cases for which the trust is deemed responsible. This is defined as a case where the sample was taken on the fourth day or later of an admission to that trust (where the day of admission is day one). To illustrate: • admission day • admission day + 1 • admission day + 2 • admission day +3 – specimens taken on this day or later are trust appointed Frimley Park Hospital NHS FT declare all positive tests to the Health Protection Agency who apportion the case based on their own algorithm, on the basis that results after a hospital stay of 48 hours are likely to be hospital acquired. There have been 15 cases in the current year. Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers Indicator descriptor: percentage of patients receiving first definitive treatment for cancer within 62 days following an urgent GP referral for suspected cancer within a given period for all cancers Data definition: All cancer two month urgent referral to treatment wait Denominator: total number of patients receiving first definitive treatment for cancer following an urgent GP referral for suspected cancer with a given period for all cancers Numerator: number of patients receiving first definitive treatment for cancer within 62 days following an urgent GP referral for suspected cancer within a given period for all cancers About the 62 day pathway The audit focused on those patients referred urgently by their GP to the Trust with suspected cancer should be seen, diagnosed and treated within 62 days. Starting the 62 Day pathway: The starting point for this period is the receipt of the referral. The original referral can be received either: • direct from the General Medical Practitioner/General Dental Practitioner • via Choose and Book Receipt of referral is day 0 for the 62 day period.

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Ending the 62 Day pathway: The period end is the first definitive treatment. This start date may differ slightly for different treatments. The percentage of patients treated within 62 days for 2013-2014 was 89% Patient Safety Incidents Reported Indicator descriptor: patient safety incidents reported to the National Reporting and Learning Service (NRLS) Indicator construction: the number of patient safety incidents reported to the National Reporting and Learning Service (NRLS) Indicator format: whole number Safety Incidents Involving Severe Harm or Death Indicator descriptor: patient safety incidents reported to the National Reporting and Learning Service (NRLS) where degree of harm is recorded as “severe harm” or “death” as a percentage of all patient safety incidents reported Numerator: the number of patient safety incidents recorded as causing severe harm/death as described as above. The “degree of harm” for patient safety incidents is defined as follows: • Severe – the patient has been permanently harmed as a result of the patient safety incident • Death – the patient safety incident has resulted in the death of the patient Denominator: the number of patient safety incidents reported to the National Reporting and Learning Service (NRLS) Indicator format: standard percentage

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Annex V Limited Assurance Report Independent Auditors’ Limited Assurance Report to the Council of Governors of Frimley Park Hospital NHS Foundation Trust on the Annual Quality Report We have been engaged by the Council of Governors of Frimley Park Hospital NHS Foundation Trust to perform an independent assurance engagement in respect of Frimley Park Hospital NHS Foundation Trust’s Quality Report for the year ended 31 March 2014 (the ‘Quality Report’) and specified performance indicators contained therein. Scope and subject matter The indicators for the year ended 31 March 2014 in the Quality Report that have been subject to limited assurance (the “specified indicators”) consist of the following national priority indicators as mandated by Monitor:

Specified Indicators Specified indicators criteria (exact page number where criteria can be found)

Clostridium Difficile (C. Difficile) Page 67

Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers

Page 67 - 68

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 specified indicators criteria referred to on pages of the Quality Report as listed above (the "Criteria"). The Directors are also responsible for the conformity of their Criteria with the assessment criteria set out in the NHS Foundation Trust Annual Reporting Manual (“FT ARM”) and the “Detailed requirements for quality reports 2013/14” issued by the Independent Regulator of NHS Foundation Trusts (“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 does not incorporate the matters required to be reported on as specified in Annex 2 to Chapter 7 of the FT ARM and the “Detailed requirements for quality reports 2013/14”;

The Quality Report is not consistent in all material respects with the sources specified below; and The specified indicators have not been prepared in all material respects in accordance with the

Criteria and the six dimensions of data quality set out in the “2013/14 Detailed guidance for external assurance on quality reports”.

We read the Quality Report and consider whether it addresses the content requirements of the FT ARM, 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 the following documents:

o Board minutes and papers for the period April 2013 to May 2014. o Papers related to quality reported to the Board over the period April 2013 to May 2014. o Feedback from commissioners North East Hampshire and Farnham, Surrey Heath and

Bracknell and Ascot CCGs dated 16 May 2014.

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o Feedback from Patient Experience and Involvement Group on behalf of the governors dated 30 April 2014.

o Feedback from Surrey Health Scrutiny Committee (including Healthwatch) dated 21 May 2014. o The Trust’s complaints report published under regulation 18 of the Local Authority Social

Services and NHS Complaints Regulations 2009 dated July 2013. o Latest national patient survey 2013. o Latest national staff survey 2013. o Care Quality Commission quality and risk profiles dated April 2013, June 2013, July 2013,

August 2013 o Intelligent Monitoring Reports dated October 2013 and March 2014. o The Head of Internal Audit’s annual opinion over the Trusts control environment dated March

2014. 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. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (“ICAEW”) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. This report, including the conclusion, has been prepared solely for the Council of Governors of Frimley Park Hospital NHS Foundation Trust as a body, to assist the Council of Governors in reporting Frimley Park Hospital NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2014, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and Frimley Park Hospital NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 ‘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:

reviewing the content of the Quality Report against the requirements of the FT ARM and “Detailed requirements for quality reports 2013/14”;

reviewing the Quality Report for consistency against the documents specified above; obtaining an understanding of the design and operation of the controls in place in relation to the

collation and reporting of the specified indicators, including controls over third party information (if applicable) and performing walkthroughs to confirm our understanding;

based on our understanding, assessing the risks that the performance against the specified indicators may be materially misstated and determining the nature, timing and extent of further procedures;

making enquiries of relevant management, personnel and, where relevant, third parties; considering significant judgements made by the NHS Foundation Trust in preparation of the specified

indicators; performing limited testing, on a selective basis of evidence supporting the reported performance

indicators, and assessing the related disclosures; and reading documents.

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A limited assurance engagement is less in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Report in the context of the assessment criteria set out in the FT ARM and the Criteria referred to above. The nature, form and content required of Quality Reports are determined by Monitor. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS Foundation Trusts. In addition, the scope of our assurance work has not included governance over quality or non-mandated indicators in the Quality Report, which have been determined locally by Frimley Park Hospital NHS Foundation Trust. Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that for the year ended 31 March 2014,

The Quality Report does not incorporate the matters required to be reported on as specified in Annex 2 to Chapter 7 of the FT ARM and the “Detailed requirements for quality reports 2013/14”;

The Quality Report is not consistent in all material respects with the documents specified above; and the specified indicators have not been prepared in all material respects in accordance with the Criteria

and the six dimensions of data quality set out in the “2013/14 Detailed guidance for external assurance on quality reports”.

PricewaterhouseCoopers LLP Chartered Accountants Southampton 22 May 2014 The maintenance and integrity of the Frimley Park Hospital NHS Foundation Trust’s website is the responsibility of the directors; the work carried out by the assurance providers does not involve consideration of these matters and, accordingly, the assurance providers accept no responsibility for any changes that may have occurred to the reported performance indicators or criteria since they were initially presented on the website.

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Annex VI

CQC Pre inspection (2013) indicator dashboards.

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CQC Inspection data pack, 2013

Accounts 2013-14

199 (1)

2

Independent auditors’ report to the Council of Governorsof Governors of Frimley Park Hospital NHS Foundation Trust

Report on the financial statements

Our opinion

In our opinion the financial statements, defined below:

give a true and fair view of the state of the NHS Foundation Trust’s affairs as at 31 March 2014 and of its income and expenditure and cash flows for the year then ended 31 March 2014; and

have been prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2013/14.

This opinion is to be read in the context of what we say in the remainder of this report.

What we have audited

The financial statements, which are prepared by Frimley Park Hospital NHS Foundation Trust, comprise:

the Statement of Financial Position as at 31 March 2014;

the Statement of Comprehensive Income for the year ended 31 March 2014;

the Statement of Cash Flows for the year ended 31 March 2014;

the Statement of Changes in Taxpayers’ Equity for the year ended 31 March 2014; and

the notes to the financial statements, which include a summary of significant accounting policies and other explanatory information.

The financial reporting framework that has been applied in their preparation is the NHS Foundation Trust Annual Reporting Manual 2013/14 issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).

In applying the financial reporting framework, the directors have made a number of subjective judgements, for example in respect of significant accounting estimates. In making such estimates, they have made assumptions and considered future events.

What an audit of financial statements involves

We conducted our audit in accordance with International Standards on Auditing (UK and Ireland) (“ISAs (UK & Ireland)”). 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 NHS Foundation Trust’s circumstances and have been consistently applied and adequately disclosed;

the reasonableness of significant accounting estimates made by the directors; and

the overall presentation of the financial statements.

In addition, we read all the financial and non-financial information in the Annual Report and Accounts to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report.

Opinions on other matters prescribed by the Audit Code for NHS Foundation Trusts

In our opinion:

the information given in the Strategic Report and the Directors’ Report for the financial year for which the financialstatements are prepared is consistent with the financial statements; and

the part of the Directors’ Remuneration Report to be audited has been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2013/14.

3

Other matters on which we are required to report by exception We have nothing to report in respect of the following matters where the Audit Code for NHS Foundation Trusts requires us 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 2013/14 or is misleading or inconsistent with information of which we are aware from our audit. We are not required to consider, nor have we considered, whether the Annual Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls;

we have not been able to satisfy ourselves that the NHS Foundation Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources; or

we have qualified, on any aspect, our opinion on the Quality Report.

Responsibilities for the financial statements and the audit

Our responsibilities and those of the directors

As explained more fully in the Directors’ Responsibilities Statement set out on page the directors are responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view in accordance with the NHS Foundation Trust Annual Reporting Manual 2013/14.

Our responsibility is to audit and express an opinion on the financial statements in accordance with the National Health Service Act 2006, the Audit Code for NHS Foundation Trusts issued by Monitor and ISAs (UK & Ireland). Those standards require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors.

This report, including the opinions, has been prepared for and only for the Council of Governors of Frimley Park Hospital NHS Foundation Trust in accordance with paragraph 24 of Schedule 7 of the National Health Service Act 2006 and for no other purpose. We do not, in giving these opinions, accept or assume responsibility for any other purpose or to any other person to whom this report is shown or into whose hands it may come save where expressly agreed by our prior consent in writing.

Certificate We certify that we have completed the audit of the financial statements in accordance with the requirements of Chapter 5 of Part 2 to the National Health Service Act 2006 and the Audit Code for NHS Foundation Trusts issued by Monitor.

Anna Blackman (Senior Statutory Auditor) for and on behalf of PricewaterhouseCoopers LLP Chartered Accountants and Statutory Auditors Southampton

(a) The maintenance and integrity of the Frimley Park Hospital NHS Foundation Trust website is the responsibility of the directors; the work carried out by the auditors does not involve consideration of these matters and, accordingly,the auditors accept no responsibility for any changes that may have occurred to the financial statements since they were initially presented on the website.

(b) Legislation in the United Kingdom governing the preparation and dissemination of financial statements may differ from legislation in other jurisdictions.

4

FOREWORD TO THE ACCOUNTS

FRIMLEY PARK HOSPITAL NHS FOUNDATION TRUST

The accounts are prepared in accordance with paragraphs 24 and 25 of Schedule 7 to the National Health Service Act 2006.

Andrew Morris, Chief Executive

Date: 22 May 2014

5

6

Frimley Park Hospital NHS Foundation Trust - Annual Accounts 2013/14

STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED31 March 2014

2013/14 2012/13NOTE £000 £000

Operating income 2 291,895 279,594

Operating expenses 3-4 (280,945) (267,408)

OPERATING SURPLUS 10,950 12,186

Finance costsFinance income 134 323 Finance expenses - financial liabilities (66) (76) Finance expenses - unwinding of discount 12 (2) (4) on provisionsPublic Dividend Capital dividends payable (4,512) (4,292)

Net finance costs (4,446) (4,049)

SURPLUS FOR THE YEAR 6,504 8,137

Other comprehensive income:

Revaluation gain on property, plant and equipment 9,338 4,575

Impairment loss on property, plant and equipment (1,100) (1,496)

Asset disposal on property, plant and equipment 0 0

TOTAL COMPREHENSIVE INCOME 14,742 11,216

The following notes 1 to 20 form part of these accounts.

7


31 March 2014 31 March 2013

NOTE £000 £000

Non-current assets

Intangible assets 7 575 614Property, plant and equipment 8 158,548 149,957Total non-current assets 159,123 150,571

Current assets

Inventories 9 1,115 1,230Trade and other receivables 10 20,678 15,712Cash and cash equivalents 48,980 41,003Total current assets 70,773 57,945

Current liabilities

Trade and other payables 11 (22,793) (20,175) Tax payable 11 (3,355) (3,285) Other financial liabilities 11 (420) (401) Other liabilities 11 (10,670) (7,055) Provisions for liabilities and charges 12 (395) (274) Total current liabilities (37,633) (31,190) Total assets less current liabilities 192,263 177,326

Non current liabilities

Other financial liabilities 11 (706) (1,063) Provisions for liabilities and charges 12 (83) (86)

TOTAL ASSETS EMPLOYED 191,474 176,177

FINANCED BY:

TAXPAYERS' EQUITYPublic dividend capital 79,892 79,337Revaluation reserve 58,572 50,334Income and Expenditure Reserve 53,010 46,506

TOTAL TAXPAYERS' EQUITY 191,474 176,177

Andrew Morris, Chief Executive.22 May 2014

The financial statements on pages 7 to 44 were approved by the Board of Directors and signed on its behalf by

STATEMENT OF FINANCIAL POSITION AS AT31 March 2014

8

2013/14 2012/13£000 £000

Cash flows from operating activities

Operating surplus 10,950 12,186

Depreciation and amortisation 9,088 9,654Impairments 1,102 3,886Non cash donations credited to income (61) (770)Other movements in operating cash flows (4) (4)Decrease/(increase) in Inventories 115 (63)(Increase) in Trade and other receivables (5,121) (3,921)Increase/(decrease) in Trade and other payables 6,659 (788)Increase/(decrease) Provisions 116 (69)

Net cash generated from operations 22,844 20,111

Cash flows from investing activitiesInterest received 128 323Purchase of intangible assets (268) (365)Sales of Property, Plant and Equipment 0 0Purchase of Property, Plant and Equipment (10,815) (12,994)

Net cash used in investing activities (10,955) (13,036)

Cash flows from financing activities

Public dividend capital received 555 0Other loans received 71 0Other loans repaid (189) (192)Public dividend capital paid (4,287) (4,469)Interest element of finance leases (62) (76)

Net cash used in financing activities (3,912) (4,737)

Increase in cash and cash equivalents 7,977 2,338

Cash and cash equivalents at 1 April 41,003 38,665

Cash and cash equivalents at 31 March 48,980 41,003

STATEMENT OF CASH FLOWS FOR THE YEAR ENDED31 March 2014

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1

1.1

1.2

1.3

Short-term employee benefits

Pension Costs

Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave to the following period.

Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that "the period between formal valuations shall be four years, with approximate assessments in intervening years". An outline of these follows:

Expenditure on Employee Benefits

NOTES TO THE ACCOUNTS

Income

Where income is received for a specific activity which is to be delivered in the following financial year, that income is deferred.

Income from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale of contract, less costs to sell.

Accounting convention

These accounts have been prepared under the historical cost convention, modified by the revaluation of property plant and equipment. Intangible assets and inventories are measured at cost. The accounts have been prepared on a going concern basis.

Accounting policies and other information

Monitor has directed that the financial statements of NHS Foundation Trusts shall meet the accounting requirements of the NHS Foundation Trust Annual Reporting Manual which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the 2013/14 NHS Foundation Trust Annual Reporting Manual issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury’s Financial Reporting Manual (FReM) to the extent that they are meaningful and appropriate to NHS Foundation Trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.

Income in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at the fair value of the consideration receivable. The main source of income for the Trust is contracts with commissioners in respect of healthcare services.

11

a) Accounting valuation

b) Full actuarial (funding) valuation

For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the employer.

Members can purchase additional service in the NHS Scheme and contribute to money purchase AVC's run by the Scheme's approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers.

The next formal valuation to be used for funding purposes will be carried out at as at March 2012 and will be used to inform the contribution rates to be used from 1 April 2015.

c) Scheme provisions

The NHS Pension Scheme provided defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained:

The Scheme is a "final salary" scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service.

Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year. From 2011-12 the Consumer Price Index (CPI) will be used to replace the Retail Prices Index (RPI).

Early payment of a pension, with enhancement, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year's pensionable pay for death in service, and five times their annual pension for death after retirement is payable.

A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period. Actuarial assessments are undertaken in intervening years between formal valuations using updated membership data and are accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2014, is based on the valuation data as 31 March 2010, updated to 31 March 2014 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new provision is known as "pension commutation".

The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pension Accounts, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office.

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates.

The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2004. Consequently, a formal actuarial valuation would have been due for the year ending 31 March 2008. However, formal actuarial valuations for unfunded public service schemes were suspended by HM Treasury on value for money grounds while consideration is given to recent changes to public service pensions, and while future scheme terms are developed as part of the reforms to public service pension provision due in 2015.

The Scheme Regulations were changed to allow contribution rates to be set by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and appropriate employee and employer representatives as deemed appropriate.

12


1.4 Expenditure on other goods and services

1.5 Property, plant and equipment

Recognition

Property, plant and equipment is capitalised where:

- it is held for use in delivering services or for administrative purposes;- it is probable that future economic benefits will flow to, or service potential be provided to, the Trust;- it is expected to be used for more than one financial year; and- the cost of the item can be measured reliably.

- individually have a cost of at least £5,000; or- form a group of assets which individually have a cost of more than £250, collectively have a cost of at least £5,000, 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- form part of the initial setting-up cost of a new building or refurbishment of a ward or unit, irrespective of their individual or collective cost.

Measurement

Valuation

Expenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non-current asset such as property, plant and equipment.

Property, plant and equipment are capitalised if they are capable of being used for a period which exceeds one year and they:

Property, plant and equipment are stated at the lower of replacement cost or recoverable amount. On initial recognition they are measured at cost (for leased assets, fair value) including any costs, such as installation, directly attributable to bringing them into working condition. The carrying values of property, plant and equipment are reviewed for impairment in periods if events or changes in circumstances indicate the carrying value may not be recoverable. The costs arising from financing the construction of the property, plant and equipment are not capitalised but are charged to the statement of comprehensive income in the year to which they relate in accordance with Monitors' interpretation of IAS23 revised.

All land and buildings are revalued using professional valuations in accordance with IAS 16. The frequency of valuations is dependent upon changes in the fair value of the items of property, plant and equipment being revalued. 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.

All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management.

Where 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.

Land and buildings are measured subsequently at fair value, other assets are valued at depreciated cost.

13


Subsequent expenditure

Depreciation

Property, plant and equipment which has been reclassified as 'Held for Sale' ceases to be depreciated upon reclassification. Assets in the course of construction are not depreciated until the asset is brought into use or reverts to the Trust, respectively.

Revaluation and impairment

Plant and machinery, information technology equipment and furniture and fittings are depreciated on current cost basis evenly over the estimated life. The useful economic life for equipment assets is typically between 3 to 8 years for IT assets, 5 years for short life assets, 10 years for medium life assets and 15 years for long life assets.

Asset lives of buildings and dwellings are up to a maximum of 50 years.

Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are credited to operating expenditure.

Valuations are carried out by independent professionally qualified valuers in accordance with the Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation Manual.

Assets in the course of construction are valued at cost and are valued by professional valuers as part of the property, plant and equipment valuation or when they are brought into use.

The value of land for existing use purposes is assessed at existing use value. For non-operational properties including surplus land, the valuations are carried out under fair value based on alternative use.

Operational equipment was considered to have nil inflation in 2013/14 (2012/13 1.6%); based on consideration of CPI.

Additional alternative open market value figures have only been supplied for operational assets scheduled for imminent closure and subsequent disposal.

Equipment surplus to requirements is valued at net recoverable amount.

Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that future economic benefits 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 reliably determined. The carrying amount of the part replaced is derecognised. 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.

Valuations are carried out primarily on the basis of depreciated replacement cost on a modern equivalent asset basis for specialised operational property and existing use value for non-specialised operational property.

Items of property, plant and equipment are depreciated over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits on a straight line basis. Freehold land is considered to have an indefinite life and is not depreciated.

14


ii) the sale must be highly probable i.e.; - management are committed to a plan to sell the asset; - an active programme has begun to find a buyer and complete the sale; - the asset is being actively marketed at a reasonable price;

Donated property plant and equipment

- 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 and the assets are not revalued, except where the 'fair value less costs to sell' falls below the carrying amount. Assets are de-recognised when all material sale contract conditions have been met.

Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of 'other comprehensive income'.

ii) the balance in the revaluation reserve attributable to that asset before the impairment.

Where an impairment is not the result of a loss of economic benefit or service potential, decreases in asset values and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Impairments can arise when land and building valuations have been conducted by independent professionally qualified valuers.

i) the impairment charged to operating expenses; and

Where an impairment is due to a loss of economic benefit or service potential in the asset, the impairment is 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

The donated assets are subsequently accounted for in the same manner as other items of property, plant and equipment.

Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as 'Held for Sale' and instead is retained as an operational asset and the asset's economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs.

Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the donation/grant are to be consumed in a manner specified by the donor, in which case, the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met.

De-recognition

Assets intended for disposal are reclassified as 'Held for Sale' once all of the following criteria are met:

i) the asset is available for immediate sale in its present condition subject only to terms which are usual and

15


1.6 Intangible assets

Recognition

Software

Measurement

Amortisation

1.7 Inventories

1.8

Intangible assets are capitalised if they are capable of being used for a period which exceeds one year, they can be valued and have a cost of at least £5,000.

Intangible 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 potentially be provided to, the Trust and where the cost of the asset can be measured reliably.

Jointly controlled operation

Depreciated replacement cost is being used as a proxy of fair value for intangible assets. The assessment of intangible assets highlights that software held typically has a life of approximately 3 to 5 years.

Intangible assets held for sale are measured at the lower of their carrying amount or 'fair value less costs to sell'.

Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Intangible assets on the Statement of Financial Position have a life of between 3 to 5 years assigned.

The Trust accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the Surrey Pathology Services, identified in accordance with the Pathology service agreement. Accordingly both the Royal Surrey County Hospital NHS Foundation Trust and Ashford and St. Peter's Hospitals NHS Foundation Trust also account for their share of the assets, liabilities, income and expenditure in their financial statements.

Inventories are valued at the lower of cost and net realisable value. The cost of inventories is measured using the 'First In First Out ' (FIFO) method.

Software 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.

Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management. 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.

The Trust is a member of Surrey Pathology Service, which has a three way split incorporating Ashford and St. Peter's Hospitals NHS Foundation Trust and Royal Surrey County Hospital NHS Foundation Trust. This arrangement operates within the definition of a jointly controlled operation under IAS31.

16


1.9 Cash, bank and overdrafts

1.10 Financial instruments and financial liabilities

Recognition

De-recognition

Classification and measurement

Loans and receivables

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.

Cash, bank and overdraft balances are recorded at the fair value of these balances in the Trust’s cash book. These balances exclude monies held in the Trust’s bank account belonging to patients (see note 19 - Third party assets).

Interest earned on bank accounts and interest charged on overdrafts is recorded as, respectively, “interest receivable” and “interest payable” in the periods to which they relate. Bank charges are recorded as operating expenditure in the periods to which they relate.

Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive Income.

Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the Trust's normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs i.e. when receipt or delivery of the goods or services is made. Financial assets or financial liabilities in respect of assets acquired or disposed of through finance leases are recognised and measured in accordance with note 1.11 - Leases. All other financial assets and financial liabilities are recognised when the Trust becomes a party to the contractual provisions of the instrument.

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.

Financial assets are categorised as 'Loans and receivables'. Financial liabilities are classified as 'Other financial liabilities'.

Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. They are included in current assets.

The Trust's loans and receivables comprise: cash and cash equivalents, NHS receivables, accrued income and other receivables.Loans and receivables are recognised initially at fair value, net of transactions costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset.

17


1.11 Leases

Finance leases

Operating leases

Leases of land and buildings

1.12 Provisions

The Trust recognises a provision where it has a present legal or constructive obligation of uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other resources; and a reliable estimate can be made of the amount. The amount recognised in the Statement of Financial Position is the best estimate of the resources required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using the discount rates published and mandated by HM Treasury. The rate applicable for early retirement provisions and injury benefit provisions is 1.80% in real terms.

The asset and liability are recognised at the inception of the lease, and are de-recognised when the liability is discharged, cancelled or expires. The annual rental is split between the repayment of the liability and a finance cost. The annual finance cost is calculated by applying the implicit interest rate to the outstanding liability and is charged to Finance Costs in the Statement of Comprehensive Income.

Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease.

Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. Leased land is treated as an operating lease.

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.

At the Statement of Financial Position date, the Trust assesses whether any financial assets, other than those held at 'fair value through income and expenditure' are impaired. Financial assets are impaired and impairment losses are recognised if, and only if, there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.

For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset's carrying amount and the present value of the revised future cash flows discounted at the asset's original effective interest rate. The loss is recognised in the Statement of Comprehensive Income and the carrying amount of the asset is reduced through the use of a bad debt provision.

Impairment of financial assets

Where substantially all risks and rewards of ownership of a leased asset are borne by the 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.

18


1.13

1.14

1.15 Contingencies

1.16 Public dividend capital

- Possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control; or

- Present obligations arising from past events for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability.

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 Trust carries no liabilities in relation to these claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the Trust is disclosed at note 13.

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 ‘excesses’ payable in respect of particular claims are charged to operating expenses when the liability arises.

Clinical negligence costs

Non-clinical risk pooling

Average relevant net assets are calculated as a simple mean of opening and closing relevant net assets.

Contingent assets (that is, assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity’s control) are not recognised as assets, but are disclosed in the notes to the accounts where an inflow of economic benefits is probable.

Contingent liabilities are not recognised, but are disclosed in a note to the accounts unless the probability of transfer of economic benefits is remote. Contingent liabilities are defined as:

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 International Accounting Standard (IAS) 32.

A charge, reflecting the cost of capital utilised by the Trust, is paid over 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 Trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for donated assets and average daily cash balances held with the Government Banking Services and PDC dividend balance receivable or payable. In accordance with the requirements laid down by the Department of Health (as the issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the 'pre-audit' version of the annual accounts. This can result in either a payable or receivable amount being identified at each accounting year end.

19


1.17 Value Added Tax

1.18

1.19 Third party assets

1.20

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 non current assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

A transaction which is denominated in a foreign currency is translated into the functional currency at the spot exchange rate on the date of the transaction.

Where the Trust has assets or liabilities denominated in a foreign currency at the Statement of Financial Position date:

Assets belonging to third parties (such as money held on behalf of patients see note 19 of the accounts) are not recognised in the Trust's accounts since the Trust has no beneficial interest in them. However, theyare disclosed in a separate note to the accounts in accordance with the requirements of the HM Treasury Financial Reporting Manual.

Exchange gains or losses on monetary items (arising on settlement of the transaction or on re-translation at the Statement of Financial Position date) are recognised in income or expense in the period in which they arise.

Exchange gains or losses on non-monetary assets and liabilities are recognised in the same manner as other gains and losses on these items.

Foreign exchange

The functional and presentational currencies of the Trust are sterling.

Estimates and judgements are also made in respect of provisions, details of provisions are shown at note 12 to the accounts.

- monetary items (other than financial instruments measured at 'fair value through income and expenditure') are translated at the spot exchange rate on 31 March; - non-monetary assets and liabilities measured at historical cost are translated using the spot exchange rate at the date of the transaction; and - non-monetary assets and liabilities measured at fair value are translated using the spot exchange rate at the date the fair value was determined.

Critical accounting estimates and judgements

Estimates and judgements are periodically evaluated and are based on historical experience and other factors, including, expectations of future events that are believed to be reasonable under the circumstances.

The Trust holds one finance lease with prices in Euro denomination for which it is the lessee. At the inception of this contract the Euro Exchange rate was 1.4845; this was the rate used to initially account for the finance lease liability. It is considered there has been no material change to the liability during 2013/14. Payments made under the contract terms are translated at the spot rate at the time of payment.

20


The Trust has included within the accounts £10.7m of deferred income. This is considered by the Trust to be deferred income as the services for which the income has been received have not yet been delivered. The deferred income balance includes £5.7m in relation to the bowel cancer screening programme in partnership with Royal Surrey County Hospital NHS Foundation Trust. The Trust has deferred this income as management believes there may be future liabilities associated with it, particularly given the changes in the commissioning landscape for bowel cancer screening. These deferred income balances by their nature are estimates and management has made a judgement in its recognition and measurement of these. Further details can be seen within note 11.1.

A full asset valuation of the land and buildings was undertaken during 2009/10, this is updated on an annual basis with a desktop valuation exercise. The valuations have been undertaken under IFRS, the RICS advises that assumptions underpinning the concepts of fair value should be explicitly stated and identifies two potential qualifying assumptions:

"the Market Value on the assumption that the property is sold as part of the continuing enterprise in occupation" (effectively Existing Use Value); or

"the Market Value on the assumption that the property is sold following a cessation of the existing operations" (in effect the traditional understanding of Market Value).

The Department of Health has indicated that for NHS assets it requires the former assumption to be applied for operational assets, this is the approach that was taken by the DV. The Market Value used in arriving at fair value for operational assets is therefore subject to the assumption that the property is sold as part of the continuing enterprise in occupation.

In the view of the Trust there are no further estimates or judgements which if wrong could significantly affect financial performance.

1.21 Reserves

Other reserves have been created to account for differences between the Trust's opening capital debt (Public Dividend Capital on its inception as an NHS Foundation Trust) and the value of net assets transferred to it.

1.22 Charitable Funds

Material entities over which the Trust has the power to exercise control so as to obtain economic or other benefits are classified as subsidiaries and are consolidated. Their income and expenses; gains and losses; assets, liabilities and reserves; and cash flows are consolidated in full into the appropriate financial statement lines. Appropriate adjustments are made on consolidation where the subsidiary’s accounting policies are not aligned with the Trust’s or where the subsidiary’s accounting date is before 1 January or after 30 June.

Frimley Park Hospital NHS Foundation Trust is the Corporate Trustee of the Frimley Park Hospital Charity. The charity is deemed to be a subsidiary under the prescriptions of IAS27. International Accounting Standards dictate that consolidated accounts should be prepared, that include the result and Statement of Financial Position of this subsidiary undertaking.

Consolidation of the Charitable Funds with the Trusts main accounts was deemed to be immaterial for 2013/14 Accounts. The value of the Charitable Funds is circa £1.2m, income received during the year was £709k and expenditure was £435k.

Frimley Park Hospital NHS Foundation Trust is the sole beneficiary of the Frimley Park Hospital Charity. The charity registration number is 1049600 and the registered address is Portsmouth Road, Frimley, Camberley, Surrey GU16 7UJ. Accounts for the charity can be obtained from http://www.charity-commission.gov.uk

21


1.23 Losses and special payments

1.24 Changes to Accounting Policies

The following changes to accounting standards came into affect during 2013/14:

IAS 1 Presentation of financial statements (amendment).

IAS 12 - Income Taxes (amendment).

IAS 19 - (Revised) Employee Benefits.

IFRS 7 Financial Instruments: Disclosures (amendment)

IAS 27 Consolidated and separate financial statements - removal of dispensation from consolidating NHS charitable funds.

Annual improvements to IFRS 2011. This standard is potentially applicable to 2013/14 but has not yet been endorsed by the EU and therefore by HM Treasury policy is not available for NHS bodies to apply.

Standards applicable from 2014/15

IFRS 10 Consolidated Financial Statements.

IFRS 11 Joint Arrangements

IFRS 12 Disclosure of Interest in Other Entities

IAS 27 Separate Financial Statements (amendment)

IAS 28 Investments in Associates and Joint Ventures (amendment)

IAS 32 Financial Instruments: Presentation on offsetting financial assets and liabilities (amendment)

IFRS 9 Financial Instruments - this standard will eventually replace IAS 39. It is applicable for periods beginning on or after 1 January 2015, but the standard has not yet been EU endorsed and therefore by HM Treasury policy is not available for NHS bodies to apply.

IAS 13 Fair Value Measurement - this standard should be applicable for 2013/14, however, HM Treasuryhas delayed its adoption by government bodies while it finalises some adaptations. The impact on the financial statements is unknown until these adaptations are finalised.

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. The losses and special payments note is compiled directly from the losses and compensations register which reports on an accruals basis with the exception of provisions for future losses.

22


1.25 Segmental reporting

IFRS 8 defines the term of Chief Operating Decision Maker (CODM) as a group or individual whose 'function is to allocate resources to and assess the performance of the operating elements of the entity.' For the Trust the most appropriate interpretation is that the Board of Directors represents the CODM. Operational performance is monitored at the monthly Board meetings and key resource allocation decisions are agreed there.

Information is presented to the Board as a single operating segment and is under full IFRS. This has been determined to be sufficient as the Board allocates resources and assesses performance on this basis. This mirrors the information that is submitted to Monitor and enables the Board to make strategic decisions on the Annual Plan.

A reconciliation between the published accounts and the information presented to the CODM, for financial years 2013/14 and 2012/13 is shown overleaf.

The Trust generates the majority of its income from healthcare and related services. The information as displayed in the accounts reflects that which is submitted to the Board.

During 2013/14 significant income was received from the following CCGs:

NHS Surrey Heath CCG 17% of total incomeNHS North East Hampshire and Farnham CCG 36% of total income

23


Board Report as at 31 March 2014Income Statement

INCOME AND EXPENDITURE

Plan Actual VarianceINCOME AND EXPENDITURE YTD YTD YTDOperating £m £m £m

NHS Acute Activity IncomeElective Inpatients

Tariff revenue 26.653 24.828 (1.825)Non-Tariff revenue 0.089 0.083 (0.006)

Non-Elective patientsTariff revenue 73.761 73.764 0.003Non-Tariff revenue 1.964 1.964

Elective day case patients (Same day)Tariff revenue 29.542 32.513 2.971Non-Tariff revenue 0.356 0.392 0.036

OutpatientTariff revenue 43.279 47.241 3.962Non-Tariff revenue 15.040 15.874 0.834

A&ETariff revenue 12.678 12.988 0.310Non-Tariff revenue

Other NHS activityTariff revenueNon-Tariff revenue 41.955 47.114 5.159Total NHS Tariff income 185.913 191.334 5.421Total NHS Non-Tariff income 59.404 65.427 6.023NHS Acute Activity Income, Total 245.317 256.761 11.444

Private patient revenue 7.043 6.757 (0.285)Other Non Mandatory/Non protected clinical revenue 0.882 0.882Non Mandatory/Non protected revenue, Total 7.043 7.639 0.597

Research and Development revenue 0.999 1.203 0.204Education and Training revenue 4.676 5.042 0.366Donations & Grants received for PPE and Intangible AssetsParking Revenue 1.470 1.818 0.348Catering Revenue 1.498 1.662 0.164Accomodation Revenue 0.348 0.382 0.034Revenue from non-patient services to other bodies 7.322 9.392 2.070Misc. Other Operating revenue 9.876 7.996 (1.880)Other Operating revenue, Total 26.189 27.495 1.306

Operating Revenue, Total 278.549 291.895 13.347

Operating ExpensesDrugs (24.191) (27.729) (3.538)Clinical supplies (34.064) (34.125) (0.061)

Decrease (increase) in inventories of finished goods & WIPNon-clinical supplies (3.859) (4.322) (0.463)Raw Materials and Consumables Used, Total (62.114) (66.176) (4.062)

Cost of Secondary Commissioning of mandatory services (0.318) (0.319) (0.001)Employee Benefits Expenses (161.375) (171.142) (9.767)Research & Development expense (0.570) (0.612) (0.042)Education and training expenseMisc. other Operating expenses (35.476) (32.513) 2.963Operating Expenses within EBITDA, Total (259.853) (270.762) (10.909)

Depreciation and Amortisation - owned assets (8.987) (9.088) (0.101)Impairment Losses (Reversals) net (1.575) (1.102) 0.473Operating Expenses excluded from EBITDA, Total (10.562) (10.190) 0.372

Operating Expenses IFRS, Total (270.415) (280.952) (10.537)

Surplus (Deficit) from Operations 8.134 10.944 2.810

Non OperatingInterest Income 0.333 0.134 (0.199)Profit (loss) on asset disposalsNon-Operating income, Total 0.333 0.134 (0.199)Interest Expense on Finance leases (non-PFI) (0.078) (0.062) 0.016PDC dividend expense (4.449) (4.512) (0.063)Non-Operating expenses, Total (4.527) (4.574) (0.047)

Surplus (Deficit) from Continuing Operations 3.940 6.504 2.564

24


Board Report as at 31 March 2013Income Statement Plan Actual Variance

INCOME AND EXPENDITURE YTD YTD YTDOperating £m £m £m

NHS Acute Activity IncomeElective Inpatients

Tariff revenue 23.581 24.069 0.488Non-Tariff revenue 0.062 0.090 0.028

Non-Elective patientsTariff revenue 72.605 73.089 0.484Non-Tariff revenue 1.067 1.951 0.884

Elective day case patients (Same day)Tariff revenue 25.504 27.301 1.797Non-Tariff revenue 0.409 0.361 (0.048)

OutpatientTariff revenue 40.940 42.111 1.171Non-Tariff revenue 11.565 15.087 3.522

A&ETariff revenue 11.591 12.299 0.708Non-Tariff revenue

Other NHS activityTariff revenueNon-Tariff revenue 37.578 40.957 3.379

Total NHS Tariff income 174.221 178.869 4.648Total NHS Non-Tariff income 50.681 58.446 7.765NHS Acute Activity Income, Total 224.902 237.315 12.413

Private patient revenue 7.152 6.632 (0.520)Other Non Mandatory/Non protected clinical revenue 6.526 7.431 0.905Non Mandatory/Non protected revenue, Total 13.678 14.063 0.385

Research and Development revenue 0.834 0.929 0.095Education and Training revenue 4.543 4.578 0.035Donations & Grants received for PPE and Intangible Assets 0.688 0.770 0.082Parking Revenue 1.562 1.439 (0.123)Catering Revenue 1.432 1.467 0.035Accomodation Revenue 0.387 0.341 (0.046)Revenue from non-patient services to other bodies 6.680 7.168 0.488Misc. Other Operating revenue 8.921 9.230 0.309Other Operating revenue, Total 25.047 25.922 0.875

Operating Revenue, Total 263.627 277.300 13.673

Operating ExpensesDrugs (23.585) (22.596) 0.989Clinical supplies (33.949) (34.056) (0.107)Decrease (increase) in inventories of finished goods & WIPNon-clinical supplies (4.136) (3.932) 0.204Raw Materials and Consumables Used, Total (61.670) (60.584) 1.086

Cost of Secondary Commissioning of mandatory services (0.598) (0.498) 0.100Employee Benefits Expenses (153.232) (157.207) (3.975)Research & Development expense (0.444) (0.549) (0.105)Education and training expenseMisc. other Operating expenses (30.319) (35.034) (4.715)Operating Expenses, Total (246.263) (253.872) (7.609)

Depreciation and Amortisation - owned assets (7.062) (9.654) (2.592)Impairment Losses (Reversals) net (2.954) (3.886) (0.932)Operating Expenses excluded from EBITDA, Total (10.016) (13.540) (3.524)

Operating Expenses IFRS, Total (256.279) (267.412) (11.133)

Surplus (Deficit) from Operations 7.348 9.888 2.540

Non OperatingInterest Income 0.419 0.323 (0.096)Profit (loss) on asset disposalsNon-Operating income, Total 0.419 0.323 (0.096)Interest Expense on Finance leases (non-PFI) (0.129) (0.076) 0.053PDC dividend expense (4.632) (4.292) 0.340Non-Operating expenses, Total (4.761) (4.368) 0.393

Surplus (Deficit) from Continuing Operations 3.006 5.843 2.837

Adjustment made since Board Meeting due to deferred income 2.294

Surplus as per SOCI 8.137

Figures reported to the CODM are subject to rounding errors

25


2. Operating Income

2.1 Operating Income as restated2013/14 2012/13

£000 £000

Elective income 57,816 51,821Non elective income 75,728 75,040Outpatient income 63,115 57,198A&E income 12,988 12,299Other type of activity income 50,684 43,198*Other type of activity income - MOD 0 7,430Non NHS- Private patient income 6,629 6,480- Overseas patients (non-reciprocal) 128 151- NHS Injury Scheme 730 723Education and training 5,042 4,578Non-patient care services to other bodies 6,538 7,168Research and development 1,203 929Car Parking 1,818 1,439Catering 1,662 1,467Charitable and other contributions to expenditure 61 770Staff accommodation 382 341Clinical Excellence Award 412 396Creche 559 543Clinical tests 896 691Other income 5,504 6,932*

291,895 279,594

2.2 Operating Income by category2013/14 2012/13

£000 £000Commissioner requested services Income from activities 260,331 237,317Other type of activity income - MOD 0 7,430Non-Commissioner requested services- Private patient income 6,629 6,480- Overseas patients (non-reciprocal) 128 151- NHS Injury Scheme 730 723

Total Income from activities 267,818 252,101

Other income 24,077 25,254

Total operating income 291,895 277,355

NHS Injury Scheme income is subject to a provision for doubtful debts to reflect expected collection rates. The level of provision is based on historic recovery of NHS Injury Scheme debts.

Income recorded as, other type of activity income, has been included within other commissioner related income, this income related previously to MOD income which is now recovered from NHS England.

*Bowel Cancer Screening income restated from other income, now shown within Other type activity income.

26


3. Operating Expenses

3.1 Operating expenses comprise 2013/14 2012/13£000 £000

NHS expenditure on non healthcare services 1,838 1,850Purchase of healthcare from non-NHS bodies 2,733 2,618Executive directors' costs 1,011 1,066Non-executive directors' costs 146 146Staff costs 170,541 156,500Drug costs 27,384 22,370Supplies and services - clinical (excluding drug costs) 34,566 34,359Supplies and services - general 4,527 4,080Establishment 3,715 3,620Transport 703 573Premises 12,537 16,414Increase/(decrease) in bad debt provision 212 48Depreciation 8,781 9,390Amortisation on intangible assets 307 264Property, plant and equipment impairment 1,102 3,886Audit Fees - statutory audit 89 88Clinical negligence 5,819 5,151Rentals under operating leases 1,244 1,472Other expenses 3,690 3,513

280,945 267,408

3.2 Auditor's remuneration

Audit Services - Statutory Audit 2013/14 2012/13

£(exc. VAT) £(exc. VAT)Audit of the financial statements 59,306 58,463Assurance on the quality report 12,877 12,600Additional procedures performed for the NAO, as appointed auditors of the consolidated foundation trust accounts 2,291 2,258Total 74,474 73,321

2013/14 2012/13

£(exc. VAT) £(exc. VAT)Non audit fees 208,418 120,000Total 208,418 120,000

PWC also provided consultancy support for a review of Heatherwood and Wexham Park Hospital NHS Foundation Trust, the fees for this work were £56k excluding VAT.

The Board of Governors reappointed PricewaterhouseCoopers LLP (PwC) as external auditors of the Trust for a term of three years commencing 1st April 2011, with an option to extend the appointment for a further two years.

The table below sets out the fee for the audit in accordance with the Audit Code issued by Monitor in March 2014.

The Trust engaged PwC to provide training on the application of the Health Education Data (HED) system. The HED system is a benchmarking system that enables users to monitor, compare and evaluate hospital performance indicators with NHS-wide connectivity. The fees for the work performed were £53k excluding VAT.

PwC were engaged during September 2013 to assist with prepartory work for the CQC inspection, the fees for this work were £99k excluding VAT.

27


3.2 (Continued)

3.3 Operating leases

3.3.1 Arrangements containing an operating lease 2013/14 2012/13£000 £000

Payments recognised as an expense 1,244 1,472

1,244 1,472

3.3.2 Future minimum lease payments due2013/14 2012/13

£000 £000Annual payments on leases:Not later than one year 1,068 895Later than one year and not later than five years 2,451 2,882Later than five years 0 172

3,519 3,949The Trust has one significant lease arrangement;

4. Staff Costs

4.1 Staff costs 2013/14 2012/13Total Permanently

EmployedOther Total

£000 £000 £000 £000

Salaries and wages 135,531 135,531 0 126,873Social Security Costs 11,014 11,014 0 10,680Employer contributions to NHSPA 15,840 15,840 0 14,032Other pension costs 2 2 0 0Termination benefits 14 14 0 321Agency/contract/MOD staff 9,921 0 9,921 6,165Recoveries from other bodies (770) (770) 0 (505)

171,552 161,631 9,921 157,566

Costs for MOD staff shown above were £1,490k (2012/13 - £1,825k)

4.2 Staff exit packages

- During 2008/09 rental payments in respect of Aldershot Centre for Health commenced, the contract has a break clause after 10 years, payments are shown up to and including this time frame, the annual rental is £754k plus £173k service charge (2012/13 - £688k rental plus £138k service charge).

Exit packages granted to staff during the year amounted to £14k. (2012/13 £321k). All exit packages were in respect of the national Mutually Agreed Resignation scheme (MARS).

The engagement letter signed on 7th March 2014, states that the liability of PwC, its members, partners and staff (whether in contract, negligence or otherwise) shall in no circumstances exceed £1m, in the aggregate in respect of all services.

PwC is the external auditor of Frimley Park Hospital Charitable Funds, of which the Trust is the Corporate Trustee. The fees in respect of this engagement are £5k.

28


4.3 Monthly average number of persons employed2013/14 2012/13

Total Permanently Employed

Other Total

Number Number Number Numbers

Medical and dental 478 469 9 458Administration and estates 722 722 0 687Healthcare assistants and other support staff 1,018 1,018 0 943Nursing, midwifery and health visiting staff 1,143 1,124 19 1,079Nursing, midwifery and health visiting learners 17 17 0 15Scientific, therapeutic and technical staff 365 359 6 373Bank and agency staff 353 0 353 232

4,096 3,709 387 3,787

4.4 Remuneration of Directors2013/14

Total Benefits in kind

Employers Pension

Contributions

Employers NI

Remuneration

£000 £000 £000 £000 £000

Executive Directors 1,011 0 71 101 839Non Executive Directors 146 0 0 11 135

1,157 0 71 112 974

2012/13Total Benefits in

kindEmployers

Pension Contributions

Employers NI

Remuneration

£000's £000's £000's £000's £000's

Executive Directors 1,070 4 65 113 888Non Executive Directors 146 0 0 14 132

1,216 4 65 127 1,020

4.5 The following number of employees received remuneration falling within the following ranges

2013/14 2013/14 2012/13 2012/13Medical Non Medical Medical Non Medical

£100,001 - £110,000 40 0 34 0£110,001 - £120,000 20 0 20 1£120,001 - £130,000 11 1 11 0£130,001 - £140,000 11 0 9 0£140,001 - £150,000 8 0 14 0£150,001 - £160,000 8 0 4 0£160,001 - £170,000 5 0 4 0£170,001 - £180,000 3 0 2 0£180,001 - £190,000 0 0 1 0£190,001 - £200,000 1 0 0 0£200,001 - £210,000 0 1 0£220,001 - £230,000 0 0 1 0

The remuneration shown above includes non recurrent payments for additional work on Waiting List initiatives.

The only other employees whose remuneration falls within these bandings are the Trust's Executive Directors. The remuneration for these individuals is disclosed in the Remuneration Report.

29


4.6 Early retirements due to ill health

5. Better Payment Practice Code

5.1 Better payment practice code - measure of compliance

Number £000 Number £000

Total bills paid in the year 82,581 122,379 72,262 116,105Total bills paid within target 72,813 108,820 67,648 106,204Percentage of bills paid within target 88% 89% 94% 91%

5.2 The Late Payment of Commercial Debts (Interest) Act 1998

6. Finance Expenses - Financial Liabilities

2012/13£000 £000

Finance leases 62 76Interest on late payment of commercial debt 4 0

66 76

7. Intangible Assets

Intangible assets at the statement of financial position date comprise the following elements

Total Software

£000 £000 Gross cost at 1 April 2013 1,207 1,207 Additions - purchased 268 268 Reclassifications 0 0

Gross cost at 31 March 2014 1,475 1,475 Amortisation at 1 April 2013 593 593 Provided during the year 307 307

Amortisation at 31 March 2014 900 900

NBV - Purchased at 31 March 2013 614 614 NBV total at 31 March 2013 614 614

NBV - Purchased at 31 March 2014 575 575 NBV total at 31 March 2014 575 575

Intangible software assets have been assigned a life of between 3 to 5 years.

During 2013/14 there were 3 early retirement from the Trust agreed on the grounds of ill-health at a cost of £251k (2012/13 - 1 at a cost of £13k).

2012/13

2013/14

Under the Better Payment Practice Code the Trust aims to pay all valid non-NHS invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later. During the year there was an increase in bills received of approximately 14%, this has had an impact upon the percentage of bills paid within target.

An amount of £4k has been included within finance costs arising from claims made under this legislation (2012/13 - £0k).

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2,44

6 80

0

Add

ition

s - d

onat

ed

61

0 0

0 0

61

0 0

Rev

alua

tions

2,18

1 0

2,18

1 0

0 0

0 0

Impa

irmen

ts/s

urpl

uses

cha

rged

to re

valu

atio

n re

serv

e(1

,100

) 0

(1,1

00)

0 0

0 0

0 Im

pairm

ents

reco

gnis

ed in

ope

ratin

g ex

pens

es(1

,102

) (4

46)

(656

) 0

0 0

0 0

Rec

lass

ifica

tions

0 21

0 24

1 0

(451

) (8

0)

345

(265

) D

ispo

sals

0

0 0

0 0

0 0

0

Cos

t or v

alua

tion

at 3

1 M

arch

201

418

6,26

1 23

,480

11

5,81

8 2,

979

1,88

1 38

,559

3,

537

7

Acc

umul

ated

Dep

reci

atio

n at

1 A

pril

2013

26,0

89

0 1,

700

114

0 21

,987

2,

281

7 P

rovi

ded

durin

g th

e ye

ar

8,78

1 0

5,13

3 31

3 0

2,79

7 53

8 0

Acc

umul

ated

dep

reci

atio

n w

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n ou

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n re

valu

atio

n(7

,157

) 0

(6,8

33)

(324

) 0

0 0

0 D

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0 0

0 0

0 0

0 0

Dep

reci

atio

n at

31

Mar

ch 2

014

27,7

13

0 0

103

0 24

,784

2,

819

7

Net

boo

k va

lue

- Pur

chas

ed a

t 1 A

pril

2013

140,

927

21,4

10

103,

667

2,25

0 47

0 12

,034

83

1 26

5 - F

inan

ce L

ease

s 1

Apr

il 20

131,

163

0 0

615

0 54

8 0

0 - D

onat

ed a

t 1 A

pril

2013

7,86

7 0

6,30

4 0

0 1,

563

0 0

Tota

l at 1

Apr

il 20

1314

9,95

7 21

,410

10

9,97

1 2,

865

470

14,1

45

831

265

Net

boo

k va

lue

- P

urch

ased

at 3

1 M

arch

201

414

9,73

9 23

,480

10

9,35

1 2,

261

1,88

1 12

,048

71

8 0

- Fi

nanc

e Le

ases

at 3

1 M

arch

201

41,

026

0 0

615

0 41

1 0

0 -

Don

ated

at 3

1 M

arch

201

47,

783

0 6,

467

0 0

1,31

6 0

0

Tota

l at 3

1 M

arch

201

415

8,54

8 23

,480

11

5,81

8 2,

876

1,88

1 13

,775

71

8 0

Dur

ing

the

finan

cial

yea

r rev

alua

tion

of th

e fo

llow

ing

asse

ts to

ok p

lace

whi

ch re

sulte

d in

the

follo

win

g im

pairm

ents

, on

new

ly c

onst

ruct

ed a

sset

s bo

ught

into

use

whi

ch

wer

e ch

arge

d to

Sta

tem

ent o

f Com

preh

ensi

ve In

com

e: L

yon

Way

Car

Par

k £4

45k;

Inte

rven

tiona

l Rad

iolo

gy S

uite

2 £

432k

; Neo

nata

l £20

2k; C

ardi

olog

y C

entre

£23

k

Land

and

Bui

ldin

gs w

ere

reva

lued

effe

ctiv

e 31

st M

arch

201

4 by

the

Dis

trict

Val

uer,

base

d on

a d

eskt

op v

alua

tion

in a

ccor

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ith th

e M

EA

Val

uatio

n m

etho

d.

31

Frim

ley

Par

k H

ospi

tal N

HS

Fou

ndat

ion

Trus

t - A

nnua

l Acc

ount

s 20

13/1

4

8.2

Pro

pert

y, p

lant

and

equ

ipm

ent a

t the

sta

tem

ent o

f fin

anci

al p

ositi

on d

ate

com

pris

e th

e fo

llow

ing

elem

ent s

Tota

lLa

nd

Bui

ldin

gs

excl

udin

g dw

ellin

gs

Dw

ellin

gs

Ass

ets

unde

r co

nstr

uctio

n an

d pa

ymen

ts o

n ac

coun

t

Plan

t and

m

achi

nery

In

form

atio

n te

chno

logy

Fu

rnitu

re a

nd

fittin

gs

£000

£0

00

£000

£0

00

£000

£0

00

£000

£0

00

Cos

t or v

alua

tion

at 1

Apr

il 20

1216

8,78

4 21

,410

95

,762

2,

979

12,9

14

32,8

46

2,60

1 27

2 A

dditi

ons

- pur

chas

ed

11,6

36

0 8,

377

0 47

0 2,

278

511

0 A

dditi

ons

- don

ated

77

0 0

0 0

0 77

0 0

0 R

eval

uatio

n ga

ins

238

0 0

0 0

238

0 0

Impa

irmen

ts/s

urpl

uses

cha

rged

to re

valu

atio

n re

serv

e(1

,496

) 0

(1,4

96)

0 0

0 0

0 Im

pairm

ents

reco

gnis

ed in

ope

ratin

g ex

pens

es(3

,886

) 0

(3,8

86)

0 0

0 0

0 R

ecla

ssifi

catio

ns0

0 12

,914

0

(12,

914)

0

0 0

Cos

t or v

alua

tion

at 3

1 M

arch

201

317

6,04

6 21

,410

11

1,67

1 2,

979

470

36,1

32

3,11

2 27

2

Acc

umul

ated

Dep

reci

atio

n at

1 A

pril

2012

21,0

36

0 0

0 0

19,2

80

1,74

9 7

Pro

vide

d du

ring

the

year

9,

390

0 5,

857

294

0 2,

707

532

0 A

ccum

ulat

ed d

epre

ciat

ion

writ

ten

out u

pon

reva

luat

ion

(4,3

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0 (4

,157

) (1

80)

0 0

0 0

Dep

reci

atio

n at

31

Mar

ch 2

013

26,0

89

0 1,

700

114

0 21

,987

2,

281

7

Net

boo

k va

lue

- Pur

chas

ed a

t 1 A

pril

2012

139,

479

21,4

10

89,8

25

2,36

4 12

,914

11

,849

85

2 26

5 - F

inan

ce L

ease

s 1

Apr

il 20

121,

301

0 0

615

0 68

6 0

0 - D

onat

ed a

t 1 A

pril

2012

6,96

8 0

5,93

7 0

0 1,

031

0 0

Tota

l at 1

Apr

il 20

1214

7,74

8 21

,410

95

,762

2,

979

12,9

14

13,5

66

852

265

Net

boo

k va

lue

- P

urch

ased

at 3

1 M

arch

201

314

0,92

7 21

,410

10

3,66

7 2,

250

470

12,0

34

831

265

- Fi

nanc

e Le

ases

at 3

1 M

arch

201

31,

163

0 0

615

0 54

8 0

0 -

Don

ated

at 3

1 M

arch

201

37,

867

0 6,

304

0 0

1,56

3 0

0

Tota

l at 3

1 M

arch

201

314

9,95

7 21

,410

10

9,97

1 2,

865

470

14,1

45

831

265

Dur

ing

the

finan

cial

yea

r rev

alua

tion

of s

igni

fican

t ass

ets

took

pla

ce, t

his

resu

lted

in th

e fo

llow

ing

sign

ifica

nt im

pairm

ents

, on

new

ly c

onst

ruct

ed a

sset

s bo

ught

into

use

whi

ch w

ere

char

ged

to S

tate

men

t of C

ompr

ehen

sive

Inco

me:

Em

erge

ncy

Dep

artm

ent,

Day

Sur

gery

Uni

t and

Hel

ipad

£3,

074k

; Car

diol

ogy

Cen

tre £

812k

Land

and

Bui

ldin

gs w

ere

reva

lued

effe

ctiv

e 31

st M

arch

201

3 by

the

Dis

trict

Val

uer,

base

d on

a d

eskt

op v

alua

tion

in a

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danc

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ith th

e M

EA

Val

uatio

n m

etho

d.

32


8.3 Assets held at open market value

Of the totals at 31 March 2014, (2012/13) all assets were valued in line with valuation methods set out in Note 1.5.

8.3.1 Net book value of assets held under finance leases at the statement of financial position date

Total 2013/14

Dwellings Plant and Machinery

£000 £000 £000NBV as at 31 March 2014 1,026 615 411

2012/13£000 £000 £000

NBV as at 31 March 2013 1,163 615 548

8.3.2 The total amount of depreciation charged to the statement of comprehensive income in respect of assets held under finance leases and hire purchase contracts

Total 2013/14

Dwellings Plant and Machinery

£000 £000 £000Depreciation 201 64 137

2012/13£000 £000 £000

Depreciation 195 58 137

9. Inventories

31 March 2014 31 March 2013£000 £000

Materials 1,115 1,230

1,115 1,230

10. Trade and Other Receivables

Note 10.1 Amounts falling due within one year:31 March 2014 31 March 2013

£000 £000

NHS receivables 12,247 9,520Provision for impaired receivables (302) (107)Prepayments 2,807 1,970Accrued Income 802 740Other receivables 4,067 2,497NHS injury scheme income 2,002 1,875NHS injury scheme provision (945) (944)PDC dividend receivable 0 161

20,678 15,712

Included within NHS receivables is an accrued sum of £599k relating to partially completed spells of clinical activity (2012/13 - £548k).

Other receivables includes amounts for private patient billing, whilst credit control procedures are in place a bad debt provision is made in respect of any potential doubtful debts, the provision is a specific bad debt provision based on assessment of individual debts.

All inventories held relate to Pharmacy stock. During the year £38k of Pharmacy stock had expired and was written off to Statement of Comprehensive Income as an expense, £11k of breakages were also expensed.

33


Note 10.2 Provision for impairment of receivables

31 March 2014 31 March 2013£000 £000

At 1 April 107 102Increase in Provision 236 48Amounts utilised (17) (43) Unused amounts reversed (24) 0At 31 March 302 107

Increase/(decrease) in bad debt provision (charged to Operating Expenses)

31 March 2014 31 March 2013£000 £000

Increase in provision 236 48Unused amounts reversed (24) 0Charged to Operating Expenses 212 48

31 March 2014 31 March 2013£000 £000

In three to six months 0 0Over six months 302 107Total 302 107

Note 10.4 Ageing of non-impaired receivables past their due date31 March 2014 31 March 2013

£000 £000Up to three months 9,609 9,535In three to six months 4,011 550Over six months 0 127Total 13,620 10,212

11. Trade and other payables

11.1 Trade and other payables at the statement of financial position date are made up of:

31 March 2014 31 March 2013£000 £000

Current liabilitiesNHS payables 2,740 2,815Capital payables 418 1,058Accruals 17,222 13,549PDC Payable 64 0Other payables 2,349 2,753

Trade and other payables 22,793 20,175

Tax payable (inlcuding social security costs) 3,355 3,285

Obligations under finance leases and hire purchase contracts 239 220Other loans 181 181Other liabilities: deferred income 10,670 7,055

37,238 30,916Non current liabilitiesObligations under finance leases and hire purchase contracts 587 826Other loans 119 237

37,944 31,979

The deferred income balance above includes £5.7m (2012/13 £5.7m) for income received in relation to the national bowel cancer screening programme. The Trust will deliver these services in future years in partnership with Royal Surrey County Hospital NHS Foundation Trust. The deferred income also includes a balance of £2.4m in respect of maternity pathway income.

Note 10.3 Ageing of impaired receivables

The Trust does not consider the above receivables past their due date to be impaired based on previous experience. The total reported above does not reconcile to note 11.1 as the total receivables balance includes receivables that are not classed as financial assets (see note 18.3) and receivables not past their due date as at 31 March 2014.

34


11.3 Finance lease obligations

2013/14 Total Plant and Machinery DwellingsPayable: £000 £000 £000Within one year 290 264 26Between one and five years 650 544 106After five years 25 0 25

965 808 157Less finance charges allocated to future periods (139) (86) (53)Net lease liabilities 826 722 104not later than one year 239 221 18later than one year and not later than five years 571 501 70later than five years 16 0 16

2012/13 Total Plant and Machinery DwellingsPayable: £000 £000 £000Within one year 285 259 26Between one and five years 914 808 106After five years 52 0 52

1,251 1,067 184Less finance charges allocated to future periods (205) (143) (62)Net lease liabilities 1,046 924 122not later than one year 220 202 18later than one year and not later than five years 792 722 70later than five years 34 0 34

11.4 Future finance lease obligationsPlant and Machinery Dwellings

2013/14 2013/14Minimum number of payments 3 24Number of years of commitment 3 6

Plant and Machinery Dwellings2012/13 2012/13

Minimum number of payments 4 28Number of years of commitment 4 7

The underlease states:

Plant and Machinery finance lease obligations consist of a managed service contract for the provision of services to Pathology, comprised of equipment and service elements.

Dwellings consist of a finance lease in respect of a residential accommodation block, this is governed by both a lease and underlease, the minimum payments are based on quarterly payments made per annum.

1. The basic rent is calculated as being the sum which represented the gross annual amount payable at the time of such calculation if the sum of £440,000 was borrowed on a five year fixed interest rate (including the Landlord's half percent margin) for a period of 25 years.

2. In the event that interest rates rise or fall the basic rent shall be adjusted upwards or downwards on the review dates according to the extent to which five year fixed interest rates (including the Landlord's half percent margin) exceed or fall short of 10.89% per annum calculated on £440,000 as in paragraph 1 above.

11.2 Prudential borrowing limit - the prudential borrowing code requirements in section 41 of the NHS Act 2006 have been repealed with effect from 1 April 2013 by the Health and Social Care Act 2012. The financial statements disclosures that were provided previously are no longer required.

35


12. Provisions for Liabilities and Charges

Total Pensions - other staff

Other legal claims

Other

£000 £000 £000 £000At 1 April 2013 360 124 37 199Arising during the year 324 0 22 302Utilised during the year (181) (38) (13) (130)Reversed unused (27) 0 (27) 0Unwinding of discount 2 2 0 0

At 31 March 2014 478 88 19 371

Expected timing of cash flows:Within one year 395 5 19 371Between one and five years 83 83 0 0After five years 0 0 0 0

478 88 19 371

12.1 Provisions for Liabilities and Charges 2012/13

Total Pensions - other staff

Other legal claims

Other

£000 £000 £000 £000At 1 April 2012 429 158 48 223Arising during the year 234 0 35 199Utilised during the year (170) (38) (6) (126)Reversed unused (137) 0 (40) (97)Unwinding of discount 4 4 0 0

At 31 March 2013 360 124 37 199

Expected timing of cash flows:Within one year 274 38 37 199Between one and five years 86 86 0 0After five years 0 0 0 0

360 124 37 199

£000VAT partial exemption 118Carbon management provision 115HMRC 138Total other provisions 371

Pensions provisions have been calculated using figures provided by the NHS Pensions Agency, they assume certain life expectancies. Whilst this provides a degree of uncertainty in respect of both timing and total amounts, these estimates are based upon best available actuarial information. The Trust provides for legal or constructive obligations that are of uncertain timing or amount at the Statement of Financial Position date on the basis of the best estimate of the expenditure required to settle the obligation. Other provisions consist of the following which are also of uncertain timing and amount.

36


13. Clinical negligence liabilities2013/14 2012/13

£000 £000

30,659 31,955

14. Cash and Cash Equivalents

31 March 2014 31 March 2013£000 £000

At 1 April 41,003 38,665Net change in year 7,977 2,338At 31 March 48,980 41,003Broken down into: Cash at commercial banks and in hand 360 411 Cash with the Government Banking Service 48,620 40,592Cash and cash equivalents in Statement of Cash Flows 48,980 41,003

15. Contractual Capital Commitments

16. Post Statement of Financial Position Events

There are no material post statement of financial position events.

Commitments under capital expenditure contracts at the statement of financial position date were £1,576k (2012/13 - £513k) these are all in respect of building work being undertaken for major capital projects.

Amount included in provisions of the NHSLA in respect of Clinical Negligence liabilities of the Trust.

37


17. Related Party Transactions

2013/14 2013/14 2013/14 2013/14Income Expenditure Receivables Payables

£000 £000 £000 £000

Bath, Gloucester, Swindon & Wiltshire Area Team 8,503 0 81 54Kent & Medway Area Team 1,044 0 (11) 0Surrey & Sussex Area Team 36,064 0 2,619 0Thames Valley Area Team 1,055 0 263 0Wessex Area Team 1,489 0 30 0NHS Bracknell and Ascot CCG 29,347 0 932 689NHS Guildford and Waverley CCG 3,889 0 93 9NHS North East Hampshire and Farnham CCG 107,220 38 449 1,018NHS North Hampshire CCG 4,481 0 28 1NHS North West Surrey CCG 7,514 0 139 112NHS South Eastern Hampshire CCG 1,629 0 6 1NHS Surrey Heath CCG 50,499 0 177 431NHS Windsor, Ascot and Maidenhead CCG 1,216 0 40 13NHS Wokingham CCG 3,301 0 78 28Health Education England 4,317 0 38 0Public Health England 2,619 195 0 3Ashford and St Peters Hospitals NHS Foundation Trust 461 223 1,535 73Heatherwood and Wexham Park NHS Foundation Trust 1,788 114 1,338 0Royal Surrey County Hospital NHS Foundation Trust 1,810 5,450 1,389 1,575Brighton & Sussex University Hospitals NHS Trust 2,789 4 63 0NHS Litigation Authority 0 5,826 0 0Ministry of Defence 0 1,490 0 0NHS Property Services 0 1,362 0 510NHS Pension Scheme 0 15,949 0 2,219HMRC 0 0 0 1,783National Insurance Fund 0 11,088 0 1,611

Included within the Royal Surrey County Hospital NHS Foundation Trust expenditure balance is £3,190k for the Bowel Cancer Screening Programme as part of the Partnership Pathology Service.

The Trust had significant transactions, defined as an income/expenditure balance of over £1,000k or a receivables/ payables balance of over £500k, with the following related bodies:

The Trust who is the Corporate Trustee of the Frimley Park Hospital Charity holds charitable funds for which transactions between parties are not deemed material. Included within operating income in respect of non cash donations credited to income are £61k relating to PPE additions. (2012/13 £770k).

38


17.1 Related Party Transactions 2012/132012/13 2012/13 2012/13 2012/13Income Expenditure Receivables Payables

£000 £000 £000 £000Yorkshire and the Humber Strategic Health Authority 1,981 2 78 0Berkshire East Primary Care Trust 30,906 0 402 0Berkshire West Primary Care Trust 4,284 0 113 0Bristol Primary Care Trust 2,815 0 13 0Hampshire Primary Care Trust 110,133 843 2,833 12Surrey Primary Care Trust 93,857 467 1,630 32West Sussex Primary Care Trust 1,072 0 56 0Ashford and St Peters Hospitals NHS Foundation Trust 227 217 1,134 14Royal Surrey County Hospital NHS Foundation Trust 1,661 4,448 1,497 2,146Brighton & Sussex University Hospitals NHS Trust 4,576 4 88 0NHS Litigation Authority 0 5,139 0 2Ministry of Defence 3,715 2,618 0 0NHS Pensions Scheme 0 14,016 0 1,879HMRC 0 0 0 1,776National Insurance Fund 0 10,720 0 1,544

Included within the Royal Surrey County Hospital NHS Foundation Trust expenditure balance is £2,751k for the Bowel Cancer Screening Programme as part of the Partnership Pathology Service.

The Trust who is the Corporate Trustee holds charitable funds for which transactions between parties are not deemed material.

All income and expenditure listed is within the normal terms of business no securities are given or consideration due in settlement.

Aside from these transactions none of the Board Members, Foundation Trust Governors, members of the key management staff or parties related to them have undertaken any material transactions with the Trust.

39

18. Financial InstrumentsInternational Accounting Standards IAS 32, IAS 39 and IFRS 7, require disclosure of the role that financial instruments have had during the year in creating or changing the risks an entity faces in undertaking its activities. Because of the continuing service provider relationship that the Trust has with local NHS Commissioners and the way those NHS Commissioners are financed, the Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of the listed companies to which these standards mainly apply. The Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated through day-to-day operational activities rather than being held to change the risks facing the Trust in undertaking its activities.

Financial Risk Management

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 Treasury Management Policy agreed by the Board of Directors. Trust Treasury activity is routinely reported and is subject to review by the Trust’s internal auditors.

Currency Risk

The Trust is principally a domestic organisation with the majority of transactions, assets and liabilities being in the UK and sterling based. As such, the Trust does not normally undertake transactions in currencies other than sterling and is therefore not exposed to movements in exchange rates over time. All currency payments are translated into sterling at the exchange rate ruling on the date of the transaction. The total value of payments made in Euro denomination was 742,997 as at 31 March 2014 (2012/13 653,288). The Trust has one significant contract with prices in Euro Denomination the exchange rate at inception of the contract was 1.4845, this rate was initially used to calculate the finance lease liability, given fluctuations in exchange rates, the year endliability was restated at the prevailing exchange rate as at 31 March 2011 of 1.1375, the exchange rate difference as at 31 March 2014 is not considered to be material to warrant any further restatement. Payments made under the contract terms are translated at the spot rate at the time of payment, with any exchange gain or loss upon year end translation taken to the Statement of Comprehensive Income.

The Trust’s main exposure to interest rate fluctuations arises where it utilises external borrowings. The Trust has no external borrowing apart from several finance leases as per note 12.4 and accordingly has not been required to manage exposure to interest rate fluctuations.

Credit RiskDue to the fact that the majority of the Trust’s income comes from legally binding contracts with NHS bodies and Government departments the Trust does not believe that it is exposed to significant credit risk in relation to cash. During 2013/14 with the changes in the commissioning landscape there is perceived to be no additional credit risk in relation to cash.

The Trust's deposits are routinely monitored in accordance with guidance issued by Monitor and are overseen by the Audit Committee, the Trust typically invests in A-1 institutions for short term investments.

Liquidity RiskThe Trust's net operating costs are incurred under legally binding contracts with local CCGs, which are financed from resources voted annually by Parliament. The Trust has the potential to fund its capital expenditure from funds obtained within the Prudential Borrowing Limit. The Trust is not, therefore, exposed to significant liquidity risks.


40


18.1 Financial Instruments

Carrying Value£000

65,794

65,794

53,65353,653

23,91923,919

21,63921,639

Gross financial assets at 31 March 2013

Gross financial assets at 31 March 2014

18.1.2 Financial liabilities

Gross financial liabilities at 31 March 2014

The above financial assets have been included in the accounts at amortised cost as "loans and receivables", with no financial assets being classified as "assets at fair value through the profit and loss", "assets held to maturity" nor "assets held for resale".

Denominated in £ sterlingGross financial liabilities at 31 March 2013

18.1.1 Financial Assets

Financial assets Denominated in £ sterling

All financial liabilities are classified as "other financial liabilities", with no financial liabilities being classified as "liabilities at fair value through the I&E".

Other tax and social security payables amounts of £3,355k (2012/13 - £3,285k) and deferred income of £10,670k (2012/13 - £7,055k) are not considered to be financial instruments under IFRS and therefore have been excluded from the above analysis.

Prepayments of £2,807k (2012/13 - £1,970k) are not considered to be financial instruments.

Denominated in £ sterling

Denominated in £ sterling

41


Total Loans and receivables

Assets as per statement of financial position £000 £000 NHS receivables 12,247 12,247Provision for impaired receivables (as at 31 March 2014) (302) (302) Accrued income 802 802Other receivables 4,067 4,067Cash and cash equivalents 48,980 48,980

Total at 31 March 2014 65,794 65,794

NHS receivables 9,520 9,520Provision for impaired receivables (as at 31 March 2013) (107) (107) Accrued income 740 740Other receivables 2,497 2,497Cash and cash equivalents 41,003 41,003

Total at 31 March 2013 53,653 53,653

Total Other financial liabilities

Liabilities as per statement of financial position £000 £000 Trade and other payables (NHS) 2,740 2,740 Trade and other payables 2,349 2,349 Accruals 17,222 17,222 Capital payables 418 418 Finance lease obligations 826 826 PDC dividend payable 64 64 Other loans 300 300Total at 31 March 2014 23,919 23,919

Trade and other payables (NHS) 2,815 2,815 Trade and other payables 2,753 2,753 Accruals 13,549 13,549 Capital payables 1,058 1,058 Finance lease obligations 1,046 1,046 Other loans 418 418Total at 31 March 2013 21,639 21,639

18.3 Financial Assets by Category

18.4 Financial liabilities by category

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31 March 2014 31 March 2014Book Value Fair Value

£000 £000

65,794 65,794

65,794 65,794

Payables over 1 year - Finance Lease obligations 587 587Other 23,332 23,332

23,919 23,919

31 March 2013 31 March 2013Book Value Fair Value

£000 £000

53,653 53,653

53,653 53,653

Payables over 1 year - Finance Lease obligations 826 826Other 20,813 20,813

21,639 21,639

18.6 Maturity of financial assets

All of the Trust's financial assets mature in less than one year.

31 March 2014 31 March 2013£000 £000

Less than one year 23,332 20,813In more than one year but not more than five years 571 792In more than five years 16 34

Total 23,919 21,639

18.8 Derivative financial instruments

18.5 Fair values

Financial assets

As at 31 March 2014 there are no significant differences between fair value and carrying value of any of the Trust's financial instruments.

For financial assets and financial liabilities carried at fair value, the carrying amounts are classified as the carrying value net of the Trusts best estimates of bad and doubtful debts.

18.7 Maturity of financial liabilities

Discounted cash flows have not been performed on non-current liabilities due to the fact that the major lease is in Euros and the result would not be material.

Financial liabilities

In accordance with IAS39, the Trust has reviewed its contracts for embedded derivatives that are required to be separately accounted for if they do not meet the requirements set out in the standard.

Financial assets

Financial liabilities

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19. Third Party Assets

20. Losses and Special Payments

There were 796 cases of losses and special payments (2012/13 - 876 cases) totalling £132,000 (2012/13 - £135,000) approved during 2013/14.

There were no clinical negligence cases where the net payment exceeded £100,000 (2012/13 - nil). These would relate to payments made by the Trust and would not relate to any payments made by the NHS Litigation Authority in respect of the Trust.

There were no fraud cases where the net payment exceeded £100,000 (2012/13 - nil).

There were no personal injury cases where the net payment exceeded £100,000 (2012/13 - nil).

There were no compensation under legal obligation cases where the net payment exceeded £100,000 (2012/13 - nil).

There were no fruitless payment cases where the net payment exceeded £100,000 (2012/13 - nil).

The total costs in this note continue to be disclosed on a cash basis, under IFRS this should be on an accruals basis, however it is acknowledged that the amounts are immaterial and therefore continue to be on a cash basis.

The Trust held £1,524 cash and cash equivalents at 31 March 2014 (31 March 2013 - £1,261) which relates to monies held by the Trust on behalf of patients. This has been excluded from the cash and cash equivalents figure reported in the accounts.


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