Annual Report and Accounts and Quality Account

Transcription

Annual Report and
Accounts and Quality Account
2012/13
Taunton and Somerset NHS Foundation Trust
Annual Report and Accounts and Quality Account
2012/13
Presented to Parliament pursuant to Schedule 7,
paragraph 25(4) of the National Health Service Act
2006
Annual Report and Accounts and
Quality Account 2012/13
CONTENTS
1.
Chairman’s Report ........................................................................................................................... 1
2.
Directors’ Report and Management Commentary ........................................................................... 1
2.1 Introduction ........................................................................................................... ….
5
2.2
About the Directors ............................................................................................................ 5
2.3
Management Commentary, including the Operating and Financial Review ...................... 9
2.4
Improvements for Patients ............................................................................................... 19
2.5
Valuing Staff ..................................................................................................................... 27
2.6
Working in Partnership .................................................................................................... 35
3.
Corporate Governance and Directors’ Information ........................................................................ 38
4.
Remuneration Report..................................................................................................................... 45
5.
Council of Governors and Membership ........................................................................................ 49
6.
Sustainability................................................................................................................................... 57
7.
Regulatory Ratings ........................................................................................................................ 64
8.
Statement of the Accounting Officer .............................................................................................. 66
9.
Annual Governance Statement ...................................................................................................... 67
10. Quality Accounts Report ................................................................................................................ 73
11. Annual Accounts .......................................................................................................................... 159
1.
CHAIRMAN’S REPORT
2012/13 has been a challenging year for Taunton and Somerset NHS Foundation Trust, as it has
been for all NHS organisations. However, I am pleased to report, in spite of a rise in healthcare costs,
further growth in demand for acute services and an increasingly ageing population presenting with
ever more complex healthcare needs, that the Trust has continued to maintain and, in many areas,
improved the quality of care it delivers, safely and efficiently, while always striving to treat the Trust’s
patients with the highest levels of dignity and compassion.
Quality and safety
Delivering the highest quality, patient-centered care is at the heart of the Trust’s strategic ambitions
and fundamental to the Board’s decision making processes. I am pleased to report that, once again
this year, we have achieved some excellent results in relation to quality and safety.
In August, the Care Quality Commission (CQC) carried out an unannounced inspection of the hospital
and rated the Trust as being fully compliant in all areas. The quality and safety of our maternity
services was also recognised through the attainment of the NHS Litigation Authority’s ‘Level 2’, which
relates to the strength of the Trust’s risk management standards for maternity. Both of these
achievements demonstrate the Trust’s commitment to providing the highest possible standards of
patient care.
Minimising the risk of infection whilst patients are in hospital is also a critical part of keeping patients
safe. Sustaining continuing reduction in the level of hospital acquired infections therefore remained a
priority for the Trust during 2012/13 and it is pleasing to report that there were no cases of Trust
attributed MRSA bacteraemia. By the close of the year, the Trust had also achieved a substantial
improvement in the prevention of Clostridium difficile infections: 19 cases were recorded during
2012/13, which compares with 37 cases in 2011/12.
Throughout the year the Trust has also seen an increase in the number of patients surviving infection
in the form of sepsis, despite an increase in the number of patients being diagnosed with this
condition. Under the ‘Surviving Sepsis’ initiative, early diagnosis and prompt treatment has contributed
to saving the equivalent of two lives every month at Musgrove Park Hospital.
The achievements above provide significant assurance about the quality of the Trust’s care.
However, there has been one area of potential concern. The Trust’s Hospital Standardised Mortality
Rtio (“HSMR”) score is a measure of the number of deaths that occur within a hospital. Each year, the
index is recalculated / rebased from the results of all trusts. Whilst our results last year compared
favourable with other trusts and ranked us 26th in the country, our results for April 2012 to January
2013 show us as currently 80th out of 146 trusts. Scrutiny of performance across the basket of 56
diagnoses reported in HSMR has not identified any specific areas of poor performance. However, we
aspire to be in the top 20% in the country and therefore the Board will continue to monitor this
carefully on a monthly basis.
Since April 2013, every NHS hospital has been required to ask patients formally about their
experience using the ‘friends and family test’. Gaining a strong understanding of patient experience
has long been important to the Trust and, for many years, the Trust has been active in asking patients
and their families to provide feedback about their experience, to enable the Trust to improve the care
and service it provides.
The recently published Francis Report highlighted the paramount importance of staff adhering to
appropriate values and behavioural standards while they are caring for patients. Ensuring that all staff
understand the values and form of behaviour that are appropriate to promote the highest quality
patient care and a professional, supportive working environment for all staff has also long been the
Taunton and Somerset NHS Foundation Trust - Annual Report and Accounts 2012/13
1
focus of management attention. However, there is more work to be done in improving the Trust’s
culture; the hospital does not get it right for every patient, every time, and there is scope to improve
the working environment for staff. The Board acknowledges that no hospital or care setting is immune
to failures and promoting further positive cultural change across the organisation to manage this risk
remains at the core of the Trust’s planning.
To ensure the Trust learns from the findings of the Francis Report, a steering group, comprising a
selection of staff drawn from a range of disciplines and grades, has been established to consider the
findings and recommendations of this report. In parallel with this, the Trust’s executives and senior
managers are investing significant time to ensure that all employees are able to raise any concerns
they have at the earliest opportunity, in particular, where these relate to care quality.
Service performance
The Trust has generally performed well in the delivery of care to patients during 2012/13. This is in the
context of higher than expected demand for A&E services and a higher proportion of patients
presenting with more serious and complex injuries and illnesses.
In spite of significantly increased demands on the Trust’s A&E services, the Trust has consistently
exceeded the regulatory requirement that 95% of patients are seen and discharged or transferred
within four hours of their arrival in A&E.
Overall, the Trust has also continued to exceed the national ‘Referral to Treatment’ (RTT) time
threshold of 18 weeks for admitted patients (90%) and out-patients (95%). In respect of individual
specialties, the achievement of RTT targets for Orthopaedics has continued to present significant
challenges during the year, although I am pleased to report that good progress has been made in
reducing waiting lists in Orthopaedics and, by March 2013, the Trust had exceeded the national RTT
threshold for each specialty, as well as in totality.
Over the last quarter of the year, the Trust has faced significant operational challenges, impacted by
adverse weather and heavy snowfall in January, along with a significant increase in demand,
generally, over the winter period. I am proud of the efforts of the Trust’s talented and committed staff,
who continued to deliver high standards of care and treatment during this demanding time.
Financial performance
Our main challenge was and will continue to be the delivery of the Trust’s financial plans. l am pleased
to report that we have achieved a satisfactory financial performance for 2012/13.
The Trust is reporting a surplus of £0.47m as compared to a surplus of £1.5m in the previous financial
year. Although this is a lower surplus the level of technical adjustment to reflect the change of value in
land and building (which does not affect cash balances) is £2.4m higher in 2012/13 than in 2011/12.
This means that the surplus reported before this adjustment has increased by £1.4m.
Consistently achieving a ‘surplus’ is essential to the viability of the Trust, since the accumulation of
capital from surpluses is the primary source of funding for the Trust’s investment in improvement in
new or upgraded facilities and equipment.
Key developments and achievements
The Trust continues to develop the quality of the services it provides and a number of important
developments have taken place during 2012/13. These achievements are described more fully in the
Directors’ Report and Management Commentary. Amongst the most notable of them were the Trust’s
designation as a Trauma Unit as part of a new specialist trauma network for the NHS in the South
West in April 2012 and the commencement of operations of transformed pathology services for the
Trust in June 2012 via Southwest Pathology Services LLP (SPS), an innovative joint venture between
2
Taunton and Somerset NHS Foundation Trust, Yeovil District Hospital NHS Foundation Trust and
private sector partner, Integrated Pathology Partnerships Limited (iPP). SPS aims to deliver
streamlined, high quality, cost effective pathology services for NHS trusts, GPs and other health-care
providers across the South West. A new state-of-the-art hub laboratory for the service, based on
Lisieux Way, Taunton enabling a service configuration in line with the recommendations of Lord
Carter, became operational in February 2013. The new hub laboratory will be opened formally by
Lord Carter in May 2013.
In addition, the achievements of a number of the Trust’s clinical teams demonstrate the significant
contribution the Trust makes to healthcare at both national and international levels. The hospital’s ITU
was named as the best in the country for its mortality rates, when compared to similar units, and
national statistics continue to show the Trust’s cardiology team as one of the best in the country for
the speed with which patients are treated, via balloon angioplasty, following a heart attack.
The Musgrove Park Hospital estate has also been transformed by development through the year of
the £34 million Jubilee Building. The new building is due to open in early 2014 and will comprise 112
single rooms with en suite facilities to replace wards in the Trust’s Old Building.
In reflecting on the Trust’s achievements it is also worth highlighting that the Trust celebrated five
years of being a Foundation Trust in December 2012. The achievements across this period reflect the
strength of the Musgrove team and encompass the work of staff, governors and volunteers.
Board and Employees
In February 2013, Greg Dix, Director of Nursing and Governance, left the Trust to take up a similar
position with a bigger teaching hospital in the South West. He was succeeded by Carol Dight, the
Trust’s Director of Operations and a former nurse, currently serving in an interim capacity as Director
of Nursing until a substantive appointment is made following a recruitment process, now in progress.
Governance is currently being overseen by the Deputy Chief Executive.
There have also been a number of changes to the non-executive directorate during the year. Dr.
Elizabeth Driver left the Board in January 2013 and we were delighted to welcome two new nonexecutive directors, Stephen Harrison and Brian Perowne, whose appointments ensure the Trust now
has a full complement of non-executive directors.
I am grateful for the parts played by both Greg and Elizabeth in the Trust’s development in recent
years and wish them both well for the future.
It is, of course, the Trust’s staff who deserve the most praise for ensuring the Trust has performed well
this year. I am acutely aware that the current uncertainties imposed by the current financial climate,
have created anxiety for our staff. This has been exacerbated recently by the Trust’s membership of
the South West Pay Terms and Conditions Consortium. Whilst the work of the Consortium is now
complete, our involvement in it has been important and was driven by an aim to increase the flexibility
of the way in which staff may be rewarded. This is because the Trust Board believes strongly that
strong performance should be appropriately rewarded and is keen to see changes in the pay structure
which will enable this principle to be better adopted. The Trust’s management has spent time listening
to and supporting staff through this period of uncertainty and I extend my thanks, on behalf of all the
Board, for their participation in listening events and for the hard work, loyalty and dedication they have
shown.
GPs, Governors and Volunteers
On behalf of the Trust Board I would also like to thank three other important groups of people. These
are, firstly, GPs across Somerset and the Trust’s other colleagues in commissioning, who have
worked in partnership to effect a smooth transition as the new commissioning arrangements come into
3
force in April 2013. Secondly, I would like to thank our unpaid Council of Governors; the Governing
body has developed into an effective group, which helps to provide the Trust with greater
understanding about the interests and concerns of the public and they have generously contributed
their time to fulfilling their key role of holding the non-executive directors to account for their part in
ensuring the effective performance of the Trust Board. Finally, I would like to thank our volunteers;
they have increased in number during the year and pleasingly include a number of college students.
They provide a wide range of invaluable services for patients and the Trust is grateful to all our
volunteers for their continued support.
Outlook
The nature of the challenges being faced by the Trust are significant: the communities served by the
Trust comprise a higher proportion of older people than most other communities in England and the
demand for the Trust’s services will continue to rise as the population, with increasingly complex
needs, ages further; there is continuing uncertainty created by the move to the new commissioning
structure and this is exacerbated by the role of new remotely, rather than locally, based specialist
commissioners, who will now have responsibility for commissioning a significant portion of the Trust’s
services. Parts of the Trust’s estate are ageing and will need replacing or upgrading in the relatively
near term and the Trust will be required to effect transformational change in the delivery of services so
that, for example, care traditionally provided in hospital may increasingly be provided to patients at or
closer to home. The recently published Francis Report also provides a stark reminder of the
importance of ensuring that quality remains at the very top of the Trust’s agenda and that the Trust
goes further in engendering an appropriate culture in support of this. Many of the recommendations of
the Francis Report comprise areas that have long been high priorities for the Trust, and the Trust will
continue to invest resources in support of them, as well as to respond to others.
All of these things must be delivered against a backdrop of financial constraint that is unprecedented
in the history of the NHS. However, the Trust will enjoy some of the most modern and comfortable
accommodation in the NHS when the Jubilee Building opens next year, to the advantage of many of
its in-patients and there is a talented management team in place at the Trust, which in combination
with dedicated and committed staff across the Trust, mean it is well placed to face the challenges and
to continue its quest to be an exemplary provider of healthcare, supporting people in and out of
hospital to maintain their health and wellbeing.
Rosalinde Wyke
Chairman
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2.
DIRECTORS’ REPORT AND MANAGEMENT
COMMENTARY
2.1
INTRODUCTION
The Directors are pleased to present their report for the year ended 31 March 2013, as set out below.
The Directors’ Report incorporates a management commentary, which reports on the development and
performance of the Trust over the year.
2.2
ABOUT THE DIRECTORS
The details of directors who served during 2012/13 are set out below:
Director
Role
Date appointed
Term expires/date
of resignation
Current Directors
Rosalinde Wyke
Non-Executive Chairman
1 August 2006
(reappointed 1
August 2010)
1 January 2009
(re-appointed 1
January 2012)
1 January 2011
17 September 2007
(reappointed 16 Sep
11)
1 July 2011
1 March 2013
1 April 2013
31 July 2014
Gill McComas
Non-Executive Director
(Senior Independent
Director)
(Vice-Chair)
Gavin Gracie
Chris Harvey
Derek Manuel
Brian Perowne
Stephen Harrison
Colin Close
(Shadow from 13 02 13)
Chief Executive
Deputy Chief Executive
Director of Corporate
Planning and Performance
Medical Director
Simon Wombwell
Carol Dight
Director of Finance & IT
Acting Director of Nursing
Jo Cubbon
Peter Lewis
David Allwright
31 December 2015
31 December 2014
16 September 2014
30 June 2015
28 February 2017
31 March 2017
1 April 2008
1 April 2005
1 April 2001
1 October 2011
(Substantive from 1
April 2012)
14 February 2011
23 February 2013
Directors who are no longer in office
Dr Elizabeth Driver
Gregory Dix
Director of Nursing and
Governance
1 July 2011
8 November 2010
(Substantive from 10
November 2011)
21 January 2013
15 February 2013
Further information about the Trust’s current directors is provided below:
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Rosalinde Wyke, Non-Executive Director, Chairman
Rosalinde has had a career in operations and senior management within the
international finance and business information industry. A former full-time
carer, Rosalinde is active in the management of a number of community
organisations, which includes serving as Chairman of a Parish Council.
She is a PPE graduate with post-graduate training in accounting, information
science, change management and, more recently, the IOD Diploma in
Company Direction.
Prior to being appointed Chairman, Rosalinde served as a non-executive director of the Board for three
years, including two as Vice-Chairman.
She was appointed Chairman of the Trust in August 2006 and reappointed by the Council of Governors
in July 2010.
Gill McComas – Non-Executive Director (Senior Independent Director)
Gill has 25 years’ experience in the food manufacturing and retail industry. She
has worked in marketing, communications and general management for a
number of companies including United Biscuits, Premier Foods and Somerfield.
She has a particular interest and expertise in acquisitions and change
management. Married with two teenage children, Gill is also the chairperson of
the Frome and Warminster Friends Group of Children’s Hospice South West.
Chris Harvey – Non-Executive Director (Vice-Chair)
Chris lives near Tiverton and with his wife runs a small herd of pedigree cattle.
He worked in the printing and packaging industries as a board level finance
director for many years and is now a non-executive director of a large housing
association based at Weston-Super-Mare, and of a company which employs and
trains disabled people in Devon and Somerset.
Chris has a law degree from Oxford University, is a chartered accountant and
has played rugby for Bath and Somerset.
Gavin Gracie – Non-Executive Director
Gavin was born and brought up in Zimbabwe, graduating and qualifying as a
chartered accountant in South Africa. He relocated to the UK in 1989. His
early business career was primarily in the food retail, waste and aviation
sectors, although he subsequently specialised in corporate recovery. He has
operated his own consultancy in this area since 1999, advising companies and
organisations in a wide range of sectors, including an NHS PCT. As a ‘turnaround’ specialist, Gavin is experienced in helping management teams grow
and dealing with volatile and quickly changing business parameters.
In 2009, Gavin was appointed non-executive director of Premium Bars and Restaurants plc,
previously having been CEO of Zenith Group plc. Both are AIM listed groups.
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Derek Manuel – Non-Executive Director
Derek Manuel was born and educated in Taunton and joined the Trust as a
non-executive director on 1 July 2011. Since the mid-1980s Derek has been
part of divisional or global boards which have overseen major corporate activity,
including business acquisitions, mergers, joint-ventures and partnerships;
managing growth, re-organisations and restructurings; disposals and
downsizing; ownership and organisation culture change.
Between 2003 and early 2011 Derek was a board member and pension trustee
of Save the Children, responsible for the worldwide coordination of devolved Human Resources, Child
Safeguarding Facilities and Information Technology functions. In addition to his role with the Trust,
Derek is currently a non-executive director of the Crown Prosecution Service and chairs the CPS
Nominations and Governance Committee; is a board committee member for global disability charity
ADD International and a speaker in human resources strategy for the London Business School and
Cass Business School masters programmes.
Brian Perowne CB DL – Non-Executive Director
Brian joined the Trust in March 2013. He brings with him a wealth of
experience following a successful career in the Royal Navy which included
three major commands and an appointment as Head of Naval
Communications. He served as the Chief Executive of the Naval Base at
Faslane on the Clyde before being promoted to Rear Admiral in 1996. Before
retiring he was the CE of the Naval Bases and Supply Agency and served as
Chief of Fleet Support on the Admiralty and Navy Boards.
From 2001 – 2011 he was Chief Executive of The Home Farm Trust a national charity providing
support to adults with learning disabilities. He is now a Trustee of several charities, a Deputy
Lieutenant of Somerset, and a keen supporter of the Somerset Community Foundation.
Stephen Harrison – Shadow Non-Executive Director until 01 04 13
Stephen joined the Trust in February 2013 as a designate non-executive
director until his formal appointment commenced on 1 April 2013.
He has
lived in Wookey for nearly 40 years after joining Clarks Shoes for his main
career. On leaving Clarks, Stephen developed a portfolio of organisational
development consultancy work and community activity, including being
elected as leader of Mendip District Council. An interest in the NHS
developed which has seen him undertaking non-executive director roles with
Bath and West Community Trust, Mendip Primary Care Trust (where he was
appointed as Chairman), North Somerset Primary Care Trust and finally as
Chairman of a cluster of PCTs responsible for health services across Bristol, North Somerset and
South Gloucestershire. Stephen has been a Board Member of the YMCA for several years and is a
Trustee of a Daycare Centre for older people.
In his spare time Stephen is a member of Bath Rugby Club, sings in choirs and enjoys walking,
swimming and cooking.
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Jo Cubbon – Chief Executive
Jo joined the Trust as Chief Executive on 1 April 2008. She is a Registered
General Nurse and a Registered Health Visitor, and has an MBA from
Liverpool University. Clinical specialties include sexual health and child care
and community services. After a number of years in both clinical and senior
management roles, her first job as an NHS Chief Executive was at the Robert
Jones and Agnes Hunt District NHS Trust in 2000. She took up the CEO role
at Burton Hospitals before joining East Lancashire NHS Trust as CEO in 2005,
a four site, 7,000 staff hospital with an annual budget of £293m. Jo has also
worked in St Petersburg in Russia developing community health services and
education programmes.
Jo is a Non-executive director of NHS Employers and a member of the policy board. She is also
currently joint Chair of the National Staff Council.
Peter Lewis – Deputy Chief Executive
Peter joined the Trust in 2005 as Finance Director having worked in the NHS
since 1990. He was made Deputy Chief Executive in 2008 and took on the
responsibility of Chief Operating Officer in 2010. Prior to joining the Trust,
Peter was a Director of Performance at Dorset and Somerset Strategic
Health Authority. Peter is a Fellow of the Chartered Institute of Management
Accountants
David Allwright – Director of Corporate Planning and Performance
David has been an NHS manager since 1987. He joined the Trust in 2001
and has responsibility for service and capital planning, performance and
information management and contract management. He has a MA in
leadership. Before moving to Taunton in 2001 he was Assistant Chief
Executive at North Devon Healthcare Trust. Prior to this he held a number of
positions in the NHS in Hampshire, including general management posts at
Winchester and Eastleigh Healthcare Trust and senior planning and
commissioning posts in Southampton and Portsmouth Health Authorities.
Colin Close – Medical Director
Colin Close was appointed Medical Director on 1 April 2012 after
undertaking the role of Acting Medical Director since October 2011. He
qualified in 1980 and joined the Trust as a consultant physician with an
interest in endocrinology and diabetes in 1995. During his time in Taunton
he has held a variety of senior management and educational roles, including
Associate Medical Director, Director of Postgraduate Medical Education, and
latterly Head of the Severn Postgraduate School of Medicine in Bristol. His
interests beyond his specialty include improving the safety of medical care,
having led a team which won the NHS South West Safety in Healthcare
Award in 2008, and delivering high quality medical education and training.
8
Simon Wombwell – Director of Finance and IT
Simon Wombwell joined the Trust as Director of Finance and IT in February
2011. He is a Fellow of the Chartered Institute of Management Accountants
(CIMA). Prior to joining Musgrove Park he was the Director of Finance and IT for
Winchester and Eastleigh Healthcare NHS Trust for three years, and the Deputy
Director of Finance at the Oxford Radcliffe Hospitals NHS Trust for the five years
preceding. Before a spell with KPMG Consulting, Simon's career spanned a
number of NHS organisations in London beginning at the Hammersmith
Hospitals, and covering Guy's and St. Thomas', Royal Free and Regional Offices
of the Department of Health.
Carol Dight – Acting Director of Nursing
Carol joined the Trust in 2003 as Orthopaedic and Trauma Matron having
qualified as a Registered General Nurse in 1986 at Bristol Royal Infirmary. Her
clinical specialties include orthopaedics, minor injuries, neurology and general /
acute surgery. She has worked in a wide variety of clinical settings including
theatres, day surgery and ward environments, and has undertaken senior
nursing roles in both Primary and Secondary Care. In 2011 Carol moved into
the role of Divisional Director for the Planned Care Division and subsequently
into the Director of Operations role in 2012. Carol was appointed to the Acting
Director of Nursing role in February 2013, whilst continuing as Director of
Operations.
Changes in the Board of Directors
Other individuals who served as directors during the year ended 31 March 2013 are as follows:


Dr Elizabeth Driver, Non-Executive Director – resigned 31 January 2013
Greg Dix, Director of Nursing and Governance – resigned 15 February 2013
Following Greg Dix’s resignation, Carol Dight took on the role of Acting Director of Nursing.
2.3
MANAGEMENT COMMENTARY, INCLUDING THE OPERATING AND
FINANCIAL REVIEW
2.3.1 Principal Activities of the Trust during 2012/13
During 2012/13 Taunton and Somerset NHS Foundation Trust continued to provide a full
range of the services expected of a district general hospital, primarily from Musgrove Park
Hospital in Taunton. Although its major catchment area is West Somerset, it also receives
significant levels of referrals from South and North Somerset and parts of East Devon. West
Somerset is a rural area and the Trust’s consultants and supporting staff hold clinics in
community hospitals, the management of which was transferred from NHS Somerset Primary
Care Trust to the Somerset Partnership NHS Foundation Trust during 2011/12. In addition,
some of the Trust’s specialties hold clinics in Yeovil District Hospital, which serves, primarily,
the East Somerset population.
The Trust had a turnover of £256.3m in 2012/13 (2011/12: £244.6m) and employed over
3,783 (whole time equivalent) staff.
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The key drivers behind the Trust’s activities and developments continue to be patient safety,
patient experience and ‘Making the Most of Musgrove’ (which is about efficient use of
resources). These have influenced projects completed during the year. Work which began in
March 2012 on the new Jubilee Building is on track to be completed in early 2014, the Jubilee
Building will provide 112 single rooms with en-suite facilities. Once the Jubilee Building is
open, the Trust will be in a position to demolish wards 1 – 5 in the Old Building. Having all
single rooms will enable the Trust to eliminate mixed-sex accommodation, give patients
greater privacy and dignity and help prevent hospital-acquired infections. It will form one of
the most modern facilities in the NHS and should be ready to take its first patients around
March 2014. Much of the c.£34 million cost of the project will be met out of the Trust’s
existing cash resources, accumulated through efficient management of resources over recent
years, together with a loan of £12 million, which was secured during the year.
Having been awarded Trauma Unit designation in 2012, as part of the new specialist trauma
network in the NHS South region, we provide emergency care to patients with life threatening
injuries. A grant is being agreed to help us develop the Emergency Department to improve
the resuscitation room and increase the number of patient bays.
Other service developments in 2012/13 are referred to in Section 2.4.2.
The Trust has continued to work with neighbouring district hospitals, Weston Area Health
NHS Trust and Yeovil District Hospital NHS Foundation Trust, Somerset Partnership NHS
Foundation Trust (which now runs Somerset’s community hospitals) and other local
healthcare organisations, to explore opportunities for greater service integration or coordination and to improve acute healthcare across Somerset. Dialogue to explore the
potential for similar collaboration with the Royal Devon and Exeter NHS Foundation Trust for
patients across Somerset and Devon has taken place this year.
One of the biggest achievements of the year was the commencement of operations of
transformed pathology services for the Trust in June 2012 via Southwest Pathology Services
LLP (SPS) an innovative joint venture between Taunton and Somerset NHS Foundation Trust,
Yeovil District Hospital, NHS Foundation Trust and private sector partner, Integrated
Pathology Partnerships Limited (iPP). SPS aims to deliver streamlined, high quality, cost
effective pathology services for NHS trusts, GPs and other health-care providers across the
South West. A new state of the art hub laboratory for the service, based on Lisieux Way,
Taunton and enabling a service configuration in line with the recommendations of Lord Carter,
became operational in February 2013. The new hub laboratory will be opened formally by
Lord Carter in May 2013.
The recently published Francis Report highlighted the importance of staff adhering to
appropriate values and behaviours while they are caring for patients. To ensure the Board
and wider Trust learn from the findings of the Francis Report, a steering group (chaired by the
Medical Director) has been set up to look closely at the findings and recommendations of the
report and to establish working groups to look at specific areas of learning and to focus on the
quality of patient care.
During the fourth full year as a foundation trust, the Trust’s membership grew to over 14,000
and its 27 governors continue to be actively involved in understanding and influencing the
Trust’s communication and engagement with its members, the patient experience at
Musgrove Park Hospital and development of the Trust’s strategy, as well as in fulfilling their
statutory responsibilities.
Clinical activity during 2012/13 was as follows:
10
NHS Clinical Activity
2012/13
2011/12
2010/11
Elective (Spells)
42,625
41,579
43,018*
Non-Elective + Emergency Care
(Spells)
41,234
41,339
40,513
Outpatients (Attendances)
315,447
311,996
322,056
A&E (Attendances)
56,054
53,998
51,070
Deliveries
3,339
3,380
3,449
*Increase of spells due to activity in the Beacon Centre being counted for the first time.
Monitor Compliance Framework
Meeting the Clostridium difficile objective.
Year target = 44
Meeting the MRSA objective (target for year = 1)
All cancers: 31 day wait for second or subsequent
treatment:
 Surgery
 Anti-cancer drug treatments
 Radiotherapy
All cancers: 62-day wait for first treatment from:
 urgent GP referral for suspected cancer
 NHS Cancer Screening Service referral
Maximum time of 18 weeks from point of referral
to treatment in aggregate – admitted
to treatment in aggregate – non-admitted
to treatment in aggregate – patients on an
incomplete pathway
All cancers: 31-day wait from diagnosis to first
treatment
Target or
Threshold
1.0
Weighting*
2012/13
44
19
1.0
3
0
1.0
94%
98%
94%
96.7%
99.9%
98.5%
1.0
1.0
85%
90%
90%
88.6%
95.2%
92.2%
1.0
95%
96.5%
1.0
92%
93.3%
0.5
96%
98.4%
93%
94.9%
93%
96.7%
95%
96.34%
Cancer: Maximum waiting time of two weeks from
referral to date first seen:
 All urgent referrals (cancer suspected)
 For symptomatic breast patients (cancer not
initially suspected)
A&E: maximum waiting time of 4 hours from
arrival to admission/transfer/discharge.
0.5
1.0
* The weighting refers to the score which is applied to a breach of the relevant target/threshold.
If there is more than one breach the scores are accumulated.
11
The Governance risk rating is determined by reference to accumulated scores as follows:
< 1.0
≥ 1.0 < 2.0
≥ 2.0 < 4.0
≥ 4.0
2.3.2
Green
Amber-Green
Amber-Red
Red
Principal Risks and Uncertainties
Financial
The financial challenge facing us in 2013/14 will arguably be the most challenging to date.
The NHS reforms set out in the Health and Social Care Act 2012 come in to being on 1 April
2013, which brings income uncertainties associated with new commissioners for our services
in the form of GP led Clinical Commissioning Groups (CCGs), the National Commissioning
Board and Specialist Commissioners. A more significant part of our income will now come
from a multitude of commissioners. Similarly, contracting for education and research and
development activities is also reorganised. This change takes place in the continued difficult
economic conditions being faced across the UK, directly impacting on the Trust and its staff.
Assessment of health policy indicates a focus on helping patients to stay out of hospital,
supported by increased investment in community based services. Such a policy puts pressure
on Musgrove Park Hospital as new investments in acute hospital services reduce in favour of
community and primary care services.
In an environment of low investment, inflationary pressures (coupled with downward pressure
on the prices the Trust can charge) and growing demand, the Trust recognises the
requirement to increase productivity. More than ever, the challenge of ‘doing more with less’
and delivering our cost improvement target is critical.
The Trust can continue to be positive about its abilities to address the challenges. Musgove’s
£34m investment in a new ward block (the Jubilee Building) and site wide modernisation of
sustainability (carbon reduction) continues to plan. The Trust exits a difficult year from an
operational perspective and continues to deliver success against the finances. As a
foundation trust (FT), the Trust must meet the financial requirements of Monitor, the FT
regulator, and it continues to do so (see Section 7: Regulatory Ratings). A change to the
ratings is expected in 2013/14 but our plans continue to demonstrate a positive position.
The Trust’s Financial Plan for 2013/14 is to deliver a surplus of 1% of turnover (before
impairments). The Trust Board has attempted to balance the need for future strategic
investment against the Trust’s ability to deliver a challenging savings plan, incorporating the
challenging environment set out above.
The principal risks are assessed as follows:
1. Maintaining an income base which matches demand for services, supported by
community and primary care initiatives to ensure demand for hospital services is limited
to only those patients that require acute care facilities;
2. Ensuring that penalty risk is managed successfully (linked to specified infection control
and patient and ambulance waiting time targets);
3. The achievement of cost improvement plans. The Trust’s financial plans set a
requirement to achieve reductions in costs, equivalent to 5% of turnover, linked to waste
12
reduction, better prices and productivity improvement. The delivery of savings proved
particularly challenging in 2012/13 making this target a principal focus to ensure our
continued success. The Trust is beginning to embrace the need for real innovation to
transform services and recognises the need to look beyond current boundaries to do so.
4. The control of spending on major capital projects. The completion of the £34m Jubilee
Building is expected in the final quarter of 2013/14. With further investments required
across the Musgrove Park Hospital site, it will be essential to deliver capital spending
plans to budget and ensure value for money in new capital investments.
Strategic
During 2012/13 the Trust has been working closely with Somerset Primary Care Trust (PCT)
and the emerging Clinical Commissioning Group which will take responsibility for
commissioning services from April 2013. The Clinical Commissioning Group will be
responsible for the Trust’s main contract for services, which links funding to the levels of
activity delivered at the hospital.
The changes present an opportunity for the Trust to explore the challenges facing acute
hospital services in the future and to look at how solutions can be found across the health
system. Nationally, the proportion of the population aged over 65 is set to increase from 17%
in 2010 to 23% by 2035. In the same period those over 85 will rise from 1.4m to 3.5m.
Combined with the growth in people who have one or more chronic conditions, who account
for over 70% of hospital bed usage, the rise in demand on healthcare is set to continue to rise
year on year with far reaching implications for local hospitals. Identifying alternatives to
hospital admission, for example by providing enhanced care in the patient’s home, will be a
key priority for the local health service to work towards allowing the hospital to concentrate its
services on those with the highest need. In 2012 the PCT provided additional financial support
to the Trust to enable it to progress work on expanding the Accident and Emergency
Department, creating new ‘majors’ cubicles and a larger resuscitation unit to improve the
department’s ability to respond to growing demand and improve patient privacy in the area.
The Trust has also shared its ambitions with regard to future site redevelopment, recognising
the age and condition of many of its buildings, constructed in 1942 as temporary military
capacity during World War II. The Trust continues to provide maternity, paediatrics,
haematology, theatres, critical care and breast screening service in these facilities. Whilst the
Trust has continued to maintain these facilities, their longer term use represents a significant
risk for the whole health community, particularly in the light of increasingly stringent quality
standards that the Trust is required to meet.
The rise in standards and the need for sufficient critical mass in specialist areas, for example
the number of patients each specialty must see to maintain compliance, has encouraged the
Trust to explore opportunities with the Royal Devon and Exeter Hospital for a more strategic
partnership. During the year, the two trusts have looked at a range of clinical specialties to see
whether by working together and covering a much larger combined geographical area they
could deliver higher standards and better value for money for patients in Somerset and
Devon.
The Trust has continued to work closely with other hospitals in the area, including those in the
independent sector. It has received support from the Nuffield Group of Hospitals to enable
some patients to be treated there to help the Trust reduce waiting times. As the national policy
is to encourage a wider market in healthcare, the Trust is likely to face growing competition
from the independent sector. If this leads to a loss of income for less complex ‘elective’ work it
may also have a knock on impact on the Trust’s ability to provide other services cost
13
effectively. Making sure that the Trust can demonstrate responsive and high quality services
will be critical to achieve the Trust’s longer term plans during a financially challenged period
for the NHS.
The NHS Act requires all NHS Trusts to become Foundation Trusts or Social Enterprises. This
will affect a number of hospitals within the South West, including Weston Area Health NHS
Trust, which runs the district general hospital in Weston-super-Mare. Weston Hospital has
confirmed that it does not believe it will be able to be a foundation trust in its own right and
therefore is looking at other organisational models. The Trust has previously discussed a
range of services that may be run in a different way using the clinical expertise at Musgrove
Park to enhance existing services in Weston. These ideas will be explored in more depth
during 2013 as part of the process for identifying a sustainable solution for Weston.
Operational
The key operational challenges facing the Trust over the coming year are:






Sustaining and improving on the current level of performance in an effective and
efficient way;
Ensuring that there is sufficient operational flexibility to meet changes in the pattern or
volume of patient demand;
Continue to reduce waiting times across all aspects of the Trust’s services and ensuring
consistent delivery of improved standards;
Continuing to meet waiting time standards within the emergency Department at the
same time as upgrading the facility;
Moving wards to the new Jubilee Build;
Operationally respond to the Trust’s recommendations from the Francis Report.
In addition, the need to develop and implement changes aimed at improving patient safety,
patient experience and cost effectiveness will present further challenges. These will need to
be managed, whilst focus is maintained on day to day operational delivery.
2.3.3 Junior Medical Staff
With the dissolution of Strategic Health Authorities, Health Education England has now
assumed responsibility for the oversight of junior doctor training and workforce planning. As of
April 2013 this will be administered regionally via Local Education and training boards
(LETBs) and Deaneries. Presently the working arrangements between LETBs, Deaneries
and Local Education providers (Trusts and GP practices) are under development and it is
expected that there will be increasing clarity over decision making processes over the coming
year.
The year to April 2013 has been characterised by the fact that none of the previous planned
reduction in trainee numbers has materialised and indeed the Trust has done well in attracting
new training posts, due to start from August 2013. It seems likely that we will be allocated
seven new training posts, four within the Foundation programme and three new posts for
doctors training to become GPs. These will be cost neutral as it is anticipated that there will
be less requirements for locums and Staff Grade/Trust doctor posts. Some posts have been
taken on without any on call commitment to minimise costs incurred. The difficulty with this
type of expansion of medical posts is that the Deanery dictates the specialty areas that the
doctors must work in, rather than the Trust’s operational requirements, and looking forward a
more strategic approach to the development of the medical workforce is required.
14
Revalidation for trainee doctors has been implemented without any significant issues,
although in time it seems likely that further modification of incident reporting procedures will
be required (for example increasing identification of individuals to inform both consultant and
trainee revalidation and appraisal processes).
The GMC has produced requirements for training and time allocation for consultants who are
supervising trainees. The Trust is in the process of implementing this – almost 100% of
consultants have completed required training levels, but ensuring appropriate allocation of
time for appraisal and educational duties requires further work.
This year’s annual GMC survey of trainees and their satisfaction with their training is ongoing.
Last year’s survey results compared favourably with other secondary care providers in the
South West. Support and supervision of more junior trainees in surgery was identified as an
area of concern, with problems both with workload / hours and intensity as well as support.
Over recent months considerable progress has been made and there are signs of significant
improvement in this area.
Summary
The Trust has had a very favourable year in terms of both trainee satisfaction and increasing
numbers of salaried trainee doctors in a range of clinical areas. Looking forward, the
challenges we face lie in the increasing variability in trainee numbers, the need to develop a
more strategic approach to all aspects of medical workforce planning, and the need to
communicate this effectively to the fledgling LETBs. Internally we need to continue to develop
excellence in our medical education and training to maximise patient safety and clinical
effectiveness and to maintain numbers of Doctors in training that are placed here.
2.3.4 Directors’ Statement
After making enquiries, the Directors’ have a reasonable expectation that the Trust has
adequate resources to continue in operational existence for the foreseeable future. For this
reason, the Board continues to adopt the going concern basis in preparing the accounts.
As far as the Directors are aware, there is no relevant audit information of which the Trust’s
Auditor is unaware, and the Directors’ have taken all the steps that they ought to take as
Directors’ in order to make themselves aware of any relevant audit information and to ensure
that the Auditor is aware of that information. PricewaterhouseCoopers LLP is the External
Independent Auditor for 2012/13.
The Trust has made no political or charitable donations.
The accounts have been prepared under a direction issued by Monitor.
Accounting policies for pensions and other retirement benefits are set out in note 1.3 of the
accounts (page 10) and details of the remuneration of senior employees may be found in the
Remuneration Report on page 47.
2.3.5 Personal data related incidents 2012/13
The Trust has continued to raise awareness of information governance with its staff and has
encouraged the reporting of personal data related incidents and made changes to processes
where necessary.
In accordance with the Department of Health’s requirements to secure all vulnerable
information, the Trust only allows the use of encrypted memory sticks therefore ensuring that
all removable media is suitably encrypted.
15
A number of potential breaches of personal information were investigated and the Trust took
appropriate action where necessary. However, there was one serious untoward incident
involving personal data reported during this period.
2.3.6 Operating and Financial Review
Statement of Comprehensive Income (SoCI) formerly the Income and Expenditure
Account
Despite economic and fiscal conditions presenting a continued challenge the Trust reported a surplus
of £0.47m, this compares to a surplus of £1.509m in the previous financial year.
This year’s surplus is stated after making a number of technical adjustments for the impairment of
some buildings. These impairments are as a result of an annual review by the District Valuer of the
assets held by the Trust, resulting in a reduction in the value of these assets compared to the previous
financial year. The value of the impairment relating to the estate total is set at £0.79m as compared to
£0.67m in the previous financial year. In addition, the Trust has taken a significant element of the
impairment expected in 2013/14 relating to the new Jubilee building into the 2012/13 accounts, this
amounts to a further impairment of £2.1m. Therefore total impairments in 2012/13 amount to £2.89m.
Income
The Trust has increased income from activities from £217.432m in the previous financial year to
£225.70m, an increase of £8.3m (3.8%). The greatest proportion of the Trust’s income is derived from
the patient care activities for Somerset patients, and the Trust believes this growth is a reflection of the
positive relationship maintained with its principle commissioner, NHS Somerset. Other income
sources also showed significant growth as set out in note 4.1 of the accounts. This is predominately
met with equal cost due to gross accounting of hosted Psychology Students and ordering of reagents
and consumable on behalf of the pathology Joint Venture outlined below (a combined £5.3m in total).
The Trust continues to generate a small proportion of its total income from Private Patient activities
(£1.3m/0.6%). On 1st October 2012, a change to the cap on private patient income of NHS foundation
trusts came into operation as a result of the Health and Social Care Act 2012. Foundation trusts now
have an obligation to ensure that the total income derived from their principle purpose is greater than
their total income from the provision of goods and services for any other purposes including the
provision of private healthcare. This means that the former private patient cap has been removed by
Parliament under the 2012 Act.
Expenditure
The Trust’s operating expenditure in 2012/13 amounted to £250.60m, an increase on the previous
financial year of £12.5m (5.2%). The level of expenditure committed by the Trust to staffing costs
amounts to 62% of operating expenditure. This is broadly consistent with previous years and other
similar organisations.
The increase in operating expenses consists of a number of key drivers. Firstly, the Trust entered into
a Joint Venture arrangement to provide pathology services using a different service model. The
impact of this has been a gross increase in cost of £5.1m in 2012/13 (£2.6m of which relates to
ordering of reagents and supplies for the JV passed on at cost). This is a net number which includes
a reduction in salaries for staff who TUPE’d under the arrangement and an increase in costs
associated with payment of invoices from the joint venture for the provision of pathology tests.
The level of impairment recognised in 2012/13 is £4.43 higher than the previous year. This is
predominately due to the part impairment of the Jubilee Building (£2.2m of the total).
16
Expenditure on high cost drugs prescribed to patients has significantly increased in 2012/13 and
accounts for £2m of the increase in operating expenditure. These costs are associated with increased
treatments for Ophthalmology related conditions, cancer treatments and Hepatitis C.
Expenditure on staff costs also increase by £6.9m (4.6%) in 2012/13 after accounting for those
pathology staff that TUPE’d to the JV. A significant element of this relates to an increased use of
agency and contract workers as well as an increased liability provided for due to an increased level of
Trust staff annual leave outstanding as at 31st March 2013.
Statement of Financial Position (SOFP) formerly Balance Sheet
The largest element on the SOFP is non-current assets (land, buildings and equipment) amounting to
st
st
£157.3m as at 31 March 2013 (£144.2m as at 31 March 2012). The increase in the Trust’s asset
base reflects its programme to replace and develop its buildings, plant and equipment for the
continuation of services to patients. As outlined above, following the annual asset review, values were
also impacted by some impairments in buildings and equipment (see Note 10 of the accounts). The
Trust had hoped that investment would be even greater in 2012/13 to reflect the ongoing development
of a new ward block (Jubilee Building), but delays in the construction schedule due to bad weather
and site issues has slipped the completion date to early 2014.
As a foundation trust, the Trust is able to fund capital expenditure through loans up to an approved
level – the Prudential Borrowing Limit (PBL). The Trust has a PBL of £64.7m disclosed in its 2012/13
accounts (£66.5m in 2011/12), and its borrowing at 31st March 2013 amounted to £33m. This
increase of £15.3m in long term liabilities is attributable to the £12m loan taken from the FT Financing
Facility , the increase in energy project related assets in the financial year with the corresponding
liability and a small increase in non-current provisions.
Other significant investments in the hospital’s infrastructure are:

Ongoing work on the Jubilee building

Completion of lift replacement programme

Replacement of CT Scanner

Computer Room and blown fibre network - improving the Trust’s IT infrastructure

Relocation of the colposcopy service to improve the inpatient experience

Replacement of major medical equipment.
The investments in 2012/13 amounted to £26.3m (£8.1m in 2011/12). Capital investment in 2013/14
is expected to exceed £31m, this includes a carry forward of £10m relating to the Jubilee Building.
The key developments are summarised as follows:

Completion of the building works relating to the Jubilee Building

Emergency Department resus reconfiguration

Electronic Patient records (EPR)

IT PACS (Clinical radiology System)

Infrastructure upgrades

Major medical equipment replacement.
17
Other features of the SOFP
The level of cash deposits has risen from £29.6m at 31 March 2012 to £34.5m at 31st March 2013.
The cash movement is detailed in the Statement of Cash Flows, which shows the Trust generated net
cash of £4.9m as at 31 03 12 (£4.6m in 2011/12), this is in part due to the Trust’s surplus, further
borrowing and partly driven by the delayed construction of the Jubilee Building.
During 2012/13 the Trust continued to work hard to reduce the age of debts owed to the Trust. The
profile of debt greater than 60 days past its due date has reduced from £1.3m as at 31 March 2012 to
£0.2m as at 31 March 2013.
Other financial issues
The Independent Regulator of foundation trusts, Monitor, assesses all foundation trusts against a
Financial Risk Rating of one to five (five being the lowest risk). The Trust’s overall financial risk rating
is a three for 2012/13 (consistent with the three achieved in 2011/12).
Financial risk ratings
Ratio
Actual
Rating
2012/13
Rating
2011/12
EBITDA Margin
6.5%
3
3
Achievement of Plan
EBITDA %
achieved
96.1%
4
5
Financial Efficiency (i)
Return on assets
1.6%
3
3
Financial Efficiency (ii)
SoCI surplus
margin
1.4%
3
2
Liquid ratio
39
4
4
3
3
Financial Criteria
Underlying Performance
Liquidity
Total Weighted Score
This Trust is also obliged to comply with the public sector’s Better Payment Practice Code (BPPC),
which requires the Trust to aim to pay all undisputed invoices by the later of the due date or 30 days
following the receipt of goods or valid invoice. Details of compliance with this code are:
18
Better Payment Practice Code
2012/13
2011/12
No
£m
No
£m
Total trade invoices paid
67,608
114.97
66,069
87.10
Total trade invoices paid within target
59,458
100.98
58,006
75.44
Percentage of trade invoices paid within
target
87.95%
87.83%
87.80%
86.61%
Note 23 of the accounts outline any related party transactions. This shows that none of the Board
members, or key management staff, or parties related to them, has undertaken any material
transactions with the Trust.
In line with the requirements for foundation trusts to prepare accounts in compliance with International
Reporting Standards, the Trust has reviewed all of its accounting policies for the year ended 31st
March 2013. No material changes have been made to those used in 2011/12.
The Trust Board acts as the corporate Trustee for the Taunton and Somerset NHS Foundation Trust
General Charitable Funds, registered with the Charities Commission. This charity also administers
charitable funds on behalf of NHS Somerset. The charity continues to receive donations from
benefactors and continues to use these funds for the benefit of both patients and staff. The charitable
Fund Annual Report and Accounts for 2012/13 are published separately and are available from the
Trust on request. We are extremely grateful for all donations made to the hospital and would like to
take the opportunity of thanking all donors for their generosity to the hospital.
Future developments
Despite continuing economic challenges, the Trust remains ambitious to develop and improve its
services to patients. Key features of the Trust’s 2013/14 plan are as follows:
2.4

Achievement of a surplus on the statement of comprehensive income (SoCI) of £0.4m (after
accounting for the residual impairment of the Jubilee Building) and EBITDA of £17.06m (7%)
to support further investments in infrastructure;

Capital investment of £31m;

Improvement plans that are required to generate £11.8m;

Continued achievement of FRR at a level 3 with a Continuity of Service score of 4 under the
expected new financial framework to be introduced by monitor in 2013/14.
IMPROVEMENTS FOR PATIENTS
2.4.1 Listening and Involving patients and stakeholders
The Trust benefits from a strong history of working closely with its patients, volunteers and
members of the public in a variety of ways. This helps its clinicians and other staff to
understand how these groups of people experience the hospital’s care and about the areas
they see as having scope for improvement. The Trust continues to develop these
relationships, recognising that they provide the Trust with rich information to assist in the
development of clinical priorities. The work of one of the working groups of the Council of
Governors, (the Patient Care Group), has been valuable in highlighting the views of both the
19
Governors and wider membership and provides further feedback for improvement. The
Trust’s quality priorities have also been determined by reference to patients, carers, staff and
members of the public.
The Trust has continued to work in partnership with LINks over the course of 2012/13 and
looks forward to working with “HealthWatch” from the 1st April 2013.
Musgrove Park Hospital undertakes a broad range of activities to understand and involve
patients, carers and the public, both formally and informally, to influence and impact upon the
hospital’s operational delivery. The hospital supports a Patient Experience Committee (PEC),
which is chaired by a patient. The PEC oversees the implementation of a strategy and annual
plan of work aimed at improving patient experience and encouraging further patient
involvement.
Public Consultation
Whilst there were no formal consultations carried out by the Trust during 2012/13,
communication to promote public awareness of a number of specific matters has continued
throughout the year and the Trust consulted widely in the development of its quality priorities
for the coming year, as set out in its Quality Accounts.
Patient Feedback
National Surveys
Two national patient surveys took place during the period 2012/13:
Care Quality Commission Inpatient Survey 2012 - A sample of 446 of the Trust’s patients
completed this survey, giving a response rate of 57% for the hospital (the nationwide average
was 48%). The survey comprised 73 questions, asking patients about their admission, care
and treatment, the staff, cleanliness, food and discharge. In respect of the Trust, three of the
areas that had shown significant improvement in 2012 were with regard to patients planned
admission and information given about their condition or treatment, providing copies of letters
between hospital doctors and GPs and giving clear written information about medicines to
patients at discharge. The 2012 results highlighted many positive aspects of the patient
experience and where the Trust’s score is significantly better than the nationwide average.
Some of these areas relate to food, important aspects of care such as confidence and Trust
privacy, emotional support and time taken to answer call bells.
Care Quality Commission Survey Accident and Emergency Department Survey 2012 - The
Trust also participated in the National A&E Survey in 2012, with 737 patients returning a
completed questionnaire (a response rate of 41%). The survey covers all aspects of a patient’s
attendance at the A&E department with a total of 42 questions. The last national survey was in
2008. In respect of the results in the 2012 survey, the Trust had significantly improved its score
on four questions, worse on one and showed no significant difference in respect of all the
remainder. Relative to the performance of other trusts, the Trust scored significantly better in
respect of 41 of the questions and worse than average in none of the questions.
In-house methods
Listening to patients views and actively seeking feedback is essential to patient-centred care.
The Trust has a ‘multi-layered’ feedback strategy. This is supported by a patient-centred
culture and the values of the hospital. The principles that underpin the strategy are:


Measurement should be continuous and the results available real time;
All patients should have the opportunity to give feedback;
20





Feedback from relatives and carers is encouraged;
Accessible to all, patients will have choice on how they feedback, with a wide range of
methods and support available for patients and families to give feedback;
Feedback and measurement of experience is core business and a standard part of
service delivery;
Feedback is used for improvement and is a core element of the Improvement Network;
The equal value of quantitative and qualitative feedback.
Specialty/Ward/Department feedback
This is feedback gained by our teams about the service they provide and giving teams the
tools and support to gain feedback and drive service improvements through the eyes of
patients. The Improvement Network has developed a tool kit to support this, examples of
approaches include patient shadowing, patient stories, surveys (a variety of methods such as
telephone, paper surveys, face to face interviewing, apps, and web/intranet online feedback),
feedback cards and focus groups.
Trust-wide rolling programme of real time survey feedback
This includes all of the hospital with surveys covering a representative and meaningful sample
size. These are more in depth surveys asking for feedback on what are known to matter most
to patients. These areas broadly relate to consistency and coordination of care, respect and
dignity, involvement, staff, cleanliness and environment, food and pain control. These surveys
are available in a number of formats - volunteer supported interviews, electronic surveys
whilst in the hospital and internet accessible surveys.
Friends and Family Test
From April 2013 all adult in-patients and patients attending Accident and Emergency will have
the opportunity to give us feedback on how likely they are to recommend Musgrove to friends
and family. From October 2013 this will include maternity with further roll out in line with
national guidance. A range of methods will be available to allow patients to take up this
opportunity at the point of discharge. In January 2013 the Trust introduced the nationallyapproved wording by asking patients if they would be likely to recommend the hospital to
family and friends. The results were 73.5% of patients said they were extremely likely to
recommend the hospital to friends or family with 94.4% of patients either extremely likely or
likely to recommend the hospital. How was it for you – Complaints Feedback
Learning from complaints and concerns provides really important feedback. Every complaint
and concern is looked at to see what we can learn and improve as a result.
Since 2011 we have been working in partnership with the Patients Association. Everyone who
has made a formal complaint is sent a survey to ask them about their experience of raising a
complaint in our hospital. The Patients Association provides a level of independence
supporting people to tell us what they think.
Patient and Public Involvement (PPI)
The hospital has a Patient Experience Committee which is chaired by a patient. This group
has membership from the local HealthWatch and the CCG. The annual programme of work
for patient experience includes working with key partners and local groups such as the
Taunton Deaf Club and Compass Disability. We also involve and seek feedback via our trust
membership which as at 31 January 2013 there are 10,706 public and 3,427 staff members.
21
The Hospital has a growing number of active volunteers who contribute hugely to the hospital.
During the year many volunteers have been recruited with new volunteering opportunities
available such as meal time volunteers and dementia support roles. Links with local colleges
have been strengthened and many students have given time volunteering in the hospital. Our
survey of volunteers and Musgrove Partners particularly help us with implementing our PPI
and patient feedback work. Musgrove Partners help with our recruitment and selection of staff,
are members of key committees across the hospital and facilitate focus groups, to name only
a few of their activities. The Trust’s Governors’ Patient Care Group reviews feedback from
patients/relatives and adds to that a regular report from the Governors on feedback they have
gained from the local community called “It’s Good to Know”.
Letters/Comments on National feedback sites
The hospital receives a huge number of thank you letters and comments which are made on
the Hospital internet or via e-mail. Each of these comments is reviewed, forwarded to the
appropriate teams / clinical areas for action as appropriate and responded to. Comments are
also made via national on-line services such as NHS Choices and Patient Opinion. From
February the PALs team will include the review and response to these in their responsibilities.
2.4.2 Developments in 2012/13 that are improving patient care
Caring for people with dementia
Nationally, there is widespread concern about the care of people with dementia in the general
hospital setting. It is estimated that 25% of general hospital beds in the NHS are occupied by
people with dementia, rising to 40% or even higher in certain groups such as elderly care
wards or in people with hip fractures. The presence of dementia is associated with longer
lengths of stay (an average of seven extra days compared to patients with similar primary
diagnoses but no dementia), delayed discharges, readmissions and inter-ward transfers
(Department of Health 2012).
The dementia challenge was launched in March 2012 by Prime Minister David Cameron and
the Trust is committed to transforming to a ‘dementia friendly’ hospital.
In 2012/13 there was the National Dementia CQUIN setting Acute Hospital Trusts the target to
screen for dementia in the 75 years+; and a local CQUIN to achieve the South West Hospital
Standards in Dementia Care – Level Two.
Assessment of patients at risk
A target was set within the national Dementia CQUIN (Commissioning for Quality
Improvement) framework for the Trust to achieve 90% of patients to be screened within 72
hours of admission to hospital by the year end.
By the third quarter the Trust had achieved 74% which is on trajectory for the year end. It has
been accepted nationally that 72 hours gives insufficient time to test for dementia as patients
are often still too unwell for the test questions to be answered.
Confirming diagnosis
A set of tests to confirm diagnosis has been agreed nationally and these are in place for use
for patients that are deemed at risk for dementia. Compliance with this process has increased
to above 90%.
22
Referring patients to specialist services
The process used to refer patients to specialist dementia services is a recommendation to the
patient’s GP at the point of discharge and this is achieved for all patients.
A dedicated Dementia Team has also completed (and continues training) with doctors,
nurses, ward-based dementia champions and support staff, e.g. therapists, on the importance
and value of good screening and how to make it meaningful.
With a re-organisation and refocus of the Dementia Strategy Group the Trust had a very
successful Peer Review in January 2013 where they commended the significant progress
made over the past 12 months, stating ‘the impressive achievements to date of the hospital
dementia team and Strategy Group’; most notably:

The team has provided strong leadership, organisation and drive to deliver a focused
work programme;

Clearly empowered Dementia champions - to be proactive, through their support and
encouragement of a ‘can do’ culture;

The training/education programme seems robust and increasingly embedded;

There are examples of clear pathways and leadership;

The volunteering within the elderly care wards works well, with a clear plan for
spread. The introduction of activity and personalising bed spaces with clear
ownership for testing this change;

Many changes to the environment have been achieved with modest investment. The
art work across the hospital, the developing use of appropriate signage, the
opportunities for patients to eat away from their bed area, all indicate that the South
West standard on environment is being implemented and is making a difference to
the quality of care.
Further improvement identified

Successful in a Bid as part of the ‘Dementia Friendly Community in Somerset Project’,
the Trust was been awarded £150k to make environmental changes to an acute
orthopaedic ward. The right environment for the care of dementia patients is a key
part of Musgrove Park Hospital’s strategy for being a dementia friendly hospital. This
work will inform the future design and build work of all environmental projects in the
hospital and part of the design strategy.

Roll out actions across the hospital 24/7 and to ensure the progress attained is
sustained going forward.

Continue training and incorporating new areas.
Patient Safety - Improvement Network
 The Improvement Network (IN) was established, under strong endorsement by the
Trust Board, in 2011 as a hospital-wide collaboration to share learning and experience
and to equip and empower the Trust’s frontline teams to take full responsibility for and
control over their patients’ outcomes. The IN’s core values and bold aims have
encouraged powerful staff engagement and stimulated impressive results:
23
Patient Safety - to keep our patients safe from avoidable harm;
Patient Experience - to give our patients the best experience possible while they are
in our care so that at least 95% of patients rate the care we provide as ‘excellent’;
Making the Most of Musgrove - to run the hospital as efficiently as possible, at a
cost of 10% less than the average hospital in England, by making sure every penny
we spend delivers the best levels of care and clinical outcomes for all patients.
 These have been our guiding principles at Musgrove for a number of years, and they
will continue to be, because they encapsulate the three areas we know we need to
focus on if we are to deliver quality care to our patients. Staff at Musgrove live and
breathe these principles and use them to shape and make improvements to the
services they provide; from staff working on the wards, in clinics and in theatres, to
staff working in our support services and management teams. Our focus on quality
has resulted in us achieving some excellent results this year. Our Intensive Therapy
Unit (ITU) has been singled out as achieving the lowest mortality (death) rates in the
country, when compared to ITUs of a similar size, meaning it is one of the safest ITUs
in England. Our infection control rates are also exemplary and are a testament to the
hard work of our staff who continuously strive to keep our patients safe from harm.
Listening to Staff
Musgrove introduced ‘Schwartz Rounds’ in November 2011 with support for the first year from
the Kings Fund. The rounds introduce a structured monthly one-hour forum for staff from all
disciplines to discuss the human and emotional side of clinical care. These rounds are an
opportunity for all who attend to participate in facilitated discussion. They provide a
supportive space for staff to reflect on the challenges of providing care to patients and their
families.
So far we have held 10 rounds with about 280 attendees from all disciplines, of which 33% of
attendees were from Nursing and Midwifery, 15% from Medical and Dental, 30% from therapy
staff and 22% from other staff groups. We have seen rounds presented by The Chief
Executive, the Medical Director as well as Specialist teams and the rounds have covered
many different topics from uniting together as a team, through to breaking bad news. The
feedback from the rounds is always really positive with 49% of attendees having attended four
or more. Staff state that they have found the rounds useful and it has helped them to reflect.
Patient Safety Walk Rounds
The Trust continues the programme of patient safety walk rounds within the hospital. All
Executive Directors are invited to participate, demonstrating top level commitment to patient
safety and experience. This process enables front line staff to share best practice and
celebrate successes in their clinical area. It is also an opportunity for the teams to discuss
patient safety issues that cause concern to the team and to work on actions to resolve the
concerns. On average there are two walk rounds achieved each month. The whole process
impacts on and improves communication between Ward and the Trust Board. Feedback
comments from all involved have been positive. Actions derived from the Walk Round are
followed up within a three month window.
24
Patient Experience - Learning from Concerns and Complaints
Feedback from our patients and their families is very important. This helps us to continuously
learn and improve what we do. During the year we received 247 formal complaints and 1,349
concerns which were raised through the Patient Advice and Liaison Service (PALs). All of
these concerns are investigated and feedback given to the person who raised the concern,
this includes setting out what we have learnt and any changes made as a result of the
concerns raised.
Notable progress and achievements during the year:

The Trust has participated in a project with the Patients Association seeking feedback
from patients and relatives who have raised a formal complaint. This feedback has
significantly helped the Trust to better understand where we need to improve our
complaint handling.

This year has seen a decrease in the number of formal complaints received by 37%
compared to last year and an increase in the number of PALs concerns. Staff across the
hospital and in PALs have worked hard to address concerns proactively at the time and to
be responsive to any concerns raised.

On the 23 January the new “front of house” PALs/information office was opened in the
Old Building. This provides patients, families and the public with an accessible point of
contact for advice and support. Alongside this new leaflets and posters have been
produced, which clearly brand PALs and make them more distinct from other information.

Working in partnership with the Patients Association, the Trust was fortunate to have the
opportunity of training provided by the Patients Association directly to staff involved in the
investigation and resolution of complaints.
The Parliamentary and Health Service Ombudsman provides an independent complaints
handling service for a range of public bodies. Should any of our complainants be dissatisfied
with the handling and outcome of their complaint they have the right to request that the
Ombudsman undertakes an independent review of their complaints. We ensure that every
complainant is given information about the role of the Ombudsman. During the year the Trust
had nine new cases referred and the following decisions were made by the Ombudsman:

2 x Local resolution was achieved

3 x Ombudsman declined to investigate
The following are just a few examples of the learning and improvements we have made:

One outcome of a complaint in A&E has been to improve the environment for patients
particularly around removing odours as it has been reported that cubicle fans can be
insufficient to clear the air.

Development of volunteer roles to support staff in improving information and support
available to patients in areas such as out-patients.

Learning from a patient’s discharge and feedback received, the policy for management of
those patients diagnosed with a heart attack has been amended by the Cardiologists.
25
Patient Care Rounds
Routinely and regularly attending to patients is an important part of nursing care. The
introduction of two-hourly formal ‘rounding’, with the intention to provide aspects of care, was
successfully tested in the Medical Assessment Unit in 2011. This was then rolled out across
all the hospital wards by July 2012 supported by staff training and a simple means of
documenting care given, and a measurement strategy to enable us to identify if improvements
are made. One important outcome of regular care-rounding should be that call bells are
answered promptly. Patients are asked about this in our monthly survey.
Healthcare Associated Infections
There were no Trust apportioned MRSA blood stream infections in 2012/13, and as of the end
of the financial year it had been 693 days since the last case. The substantial reduction in
MRSA cases over recent years has been achieved by the screening and isolation of all patients
with MRSA, an ongoing focus on hand hygiene and clean safe care of invasive devices, such
as catheters and drips.
The Trust also made a 49% reduction in the number of Clostridium difficile cases in 2012/13
compared to the previous year. In 2011/12 there were 37 Trust apportioned cases and in
2012/13 there were only 19 cases.
This significant improvement has been achieved by a continued emphasis on prudent
antibiotic prescribing, prompt isolation of patients with diarrhoea, a high standard of
environmental cleaning and regular review of affected patients by infection specialists. The
Trust continues to investigate every case that occurs to enable immediate remedial action to
be taken and to identify any learning for the future.
Service Developments
Enhanced Recovery: Enhanced recovery uses evidence based interventions to improve
patient care before, during and after surgery. Enhanced recovery has many benefits both
clinical and operational. Patients are demonstrably fitter sooner, which enables faster
rehabilitation and reduces length of stay. There are improved clinical outcomes, and
reduction in the need for on-going care interventions (or they can occur more rapidly when
needed) which improves outcome for the patient. Areas where enhanced recovery has been
implemented are primary hips and knees, colorectal surgery, gynaecology, urology and major
limb amputation in vascular surgery and gynae-oncology.
New Mould Room: A new Mould Room facility was opened at the hospital’s Beacon Centre in
October 2012. The £300k facility, enabling the fabrication of customized accessories for the
treatment of head and neck cancers and some skin cancers, was funded by the Somerset
Unit for Radiotherapy Equipment (SURE). The availability of a Mould Room in Taunton
means that such patients no longer need to travel to Bristol or Exeter for treatment.
CT Scanner: A state of the art Siemens Flash computerised tomography (CT) scanner which
provides a head to toe scan in about ten seconds without the patient having to be moved was
opened in November 2012. Funding for the scanner was supported by the hospital’s League
of Friends, whose 50th anniversary charity appeal saw them raise £350,000 towards the costs.
The CT scanner reinforces Musgrove’s commitment to providing the finest imaging facilities.
Micro surgery treatment for glaucoma: The hospital has become the second hospital in the
country to carry out new state-of-the-art micro surgery for glaucoma. Glaucoma is one of the
most common causes of blindness in the UK and it becomes more common with age. By
26
being able to offer patients this new surgery, Musgrove will be able to improve the quality of
the care patients receive while at the same time reducing the cost of treatment.
Maternity Unit: A grant of £600k from the Department of Health will enable us to make
improvements to our maternity unit. Plans are in place for the work to start in August 2013,
which includes upgrading labour ward rooms and providing more en-suite facilities.
Gould Ward: Gould Ward plans to follow the example set by Sedgemoor Ward last year by
having a makeover to create an environment which will enhance the hospital experience of
older people, and especially for those who also suffer from dementia. The improvements on
the ward will benefit all patients as well as visitors and staff.
The changes are being
supported following the success of our bid for funds from the national Dementia Challenge
Fund.
Improvements to the ward being discussed with staff include:


Colour themes for each bay to make it easier for patients and visitors to navigate their
way around the ward;
Clearer word and picture signage for the bathrooms.
Staff from Wordsworth Ward have already transformed part of their ward to create a tranquil
environment for their elderly patients.
Research and Development
During 2012/13 the hospital has continued to expand the amount of high quality clinical
research that is carried out, with research being opened in three new areas; children,
dermatology, and rheumatology. The Trust participates in national multi-centre studies and
opened 79 new research projects in the year and recruited over 1200 new patients into these
studies. In the areas of Cardiology, Diabetes and Respiratory the hospital was the best
recruiter in a number of these studies.
Dr Rob Andrews, Consultant Diabetologist, secured a grant of £250k to look at the effect of
exercise therapy early on in the treatment of Type 1 Diabetes. Mr Richard Welbourn,
Consultant Bariatric Surgeon, and Dr Rob Andrews together with colleagues at Bristol
University were successful in securing a large HTA grant (£2.8m) to conduct a randomised
control study to determine which bariatric operation, Band or Bypass, is the most effective
treatment for morbid obesity. This hospital is the lead site for this study which is the first RCT
in Bariatric surgery to be conducted in the UK.
The primary paper from a diet and exercise study run from the hospital, won the 2011 RCGP
and Novartis Diabetes Paper of the Year Award “Diet or diet plus physical activity versus
usual care in patients with newly diagnosed Type 2 diabetes: the Early ACTID randomised
controlled trial. Andrews RC et al. Lancet. 2011 Jul 9;378(9786):129-39”. The hospital was
part of a successful bid to gain funding for a South West Peninsula Academic Health Science
Network. It is anticipated that funding from this will enable further expansion of research over
the coming year.
2.5
VALUING STAFF
2.5.1
Our Staff Make the Difference
The continued efforts of our staff have helped the Trust achieve excellent results for patients
despite increasing levels of activity and significant cost pressures. Great staff are key to
27
delivering th
he best patie
ent care and the Trust’s Directors kn
now that with
hout the com
mmitment
and engage
ement of its staff, the Tru
ust would be
e unable to deliver the safe
s
and hig
gh quality
services that its patients and the pub
blic demand.
ued to work with its stafff to improve both the
During the last 12 montths the Trustt has continu
quality and productivity of its services reviewing
g Care Pathw
ways, Patien
nt Administra
ation and
e that it is
Clinical Support as well as the size, shape and skills mix of the workforcce to ensure
best placed to deliver the volume and
a
quality of
o service th
hat the Trustt is commisssioned to
deliver, and that it is affordable, he
ealthy and engaged
e
and
d sufficiently
y agile to respond to
existing and new challen
nges.
2.5.2
Workforce
e Statistics
As at the en
nd of March 2013 the Trust employe
ed 4,045 (3,4
481.9 Full Tim
me Equivale
ent [FTE])
staff. The breakdown off the Trust’s FTE
F
staffing numbers byy occupationa
al group is ass follows:
acted workfo
orce employe
ed by the Tru
ust:Of the contra

21%
% are aged 30
0 or under, 64.5%
6
are ag
ged between 31-55 & 14..5% are aged
d 56+
Taun
nton and Somerrset NHS Found
dation Trust - An
nnual Report an
nd Accounts 2012/13
28

77%
% of employee
es are femalle but there is variation in
n the gender split betwee
en staff
grou
ups

7.4 % are of Blacck Minority Ethnic
E
Origin, compared to
t 2.8% in Ta
aunton Dean
ne &
4.6%
% in the Soutth West acco
ording to 2011 census da
ata
Ethnic Origin
O
as at 31.03.13
Hea
adcount
%*
31.03.12%
White Britiish
3495
86.4
86.1 White Other
139
3.4
3.4
4 Mixed
30
0.7
0.6
6 Asian or Asian
A
British
h
145
3.6
3.3
3 Black or Black
B
British
h
29
0.7
0.7 Chinese
13
0.3
0.4
4 Any Otherr Ethnic Gro
oup
84
2.1
2.1 Not Stated
d
110
2.7
3.4
4
* percentage
es rounded to
t one decim
mal point
In addition to
o the above information, data is also collected on
n disability, with
w respondents selfreporting and this showss that 37 em
mployees havve declared a disability, 0.9%
0
of the total
t
staff
population.
mployed by the Trust automatically become me
embers of th
he Trust,
Since 2008,, all staff em
unless they choose to opt out. Priorr to that date
e staff had to
o apply to be
ecome a mem
mber. As
t staffing population,
p
w
were
membe
ers of the Fo
oundation
at 31 03 2013, 3,432 staff, 76% of the
Trust.
Taun
nton and Somerrset NHS Found
dation Trust - An
nnual Report an
nd Accounts 2012/13
29
2.5.3
Workforce Planning
As part of the integrated business planning process, the Trust has created workforce plans for
each Directorate aligned to the financial plan, to deliver service requirements over 2013/14.
This work has involved a detailed review of the baseline budgeted workforce establishment in
all areas. Clinical staffing establishments will be formally approved by the appropriate
Executive Director, to ensure that agreed staffing levels are appropriate to safeguard patient
care whilst meeting financial requirements. This will include planned use of temporary staff to
cover short term absence and additional capacity requirements, as well as substantive staff
requirements.
Anticipated changes to staffing numbers during the year, driven by the delivery of cost
improvement programmes, service development/reconfiguration plans, and planned seasonal
capacity issues, will be identified within the workforce plan.
A proactive recruitment plan by staff group will be developed, using current information about
turnover rates (retirement and leavers) against the requirements in the workforce plan.
2.5.4
Pay Modernisation
During the year the Trust has been a member of, and supported the work of, the South West
Consortium. The Trust believes the work of the Consortium has been important in helping to
inform the recent changes to the NHS pay framework and welcomes the NHS Staff Council’s
commitment to ensuring NHS staff terms and conditions remain fit for purpose in the future so
that Musgrove Park Hospital, as well as all NHS organisations, is able to provide the very best
levels of care to its patients seven days a week.
The focus of the Trust will now be to support a nationally negotiated pay framework that will
enable the hospital to deliver sustainable services to the community it serves.
2.5.5
Developing our Staff
In light of the considerable challenges ahead the Trust has committed to developing a
workforce that is capable of dealing with the complexities and changes that are required.
Leadership Matters
This development programme for senior managers has continued throughout 2012 and into
2013. Wave 2 commenced in September 2012 and has seen a further 59 delegates
participate. In total the Trust has progressed 113 of its senior managers through Leadership
Matters. Wave 3 starts in June 2013 with 15 delegates participating.
The Leadership Programme has changed since it started and now sees the programme
comprising of:





Four workshops focusing on leadership and leadership challenges
Six x 2 hour coaching sessions
360˚ survey designed for the programme
Mid-point review evaluation
Six month post-programme evaluation
Management Development
The Trust is about to commence an in house management development programme
commencing in May 2013. The programme has been designed to support the learning and
30
development of middle managers and act as a platform for those individuals wanting to
progress to senior management positions and onto the Leadership Matters programme.
Learning and Development
For 2012 e-learning has continued to be a key focus. For 2012 the Trust has developed an elearning package under core clinical skills which covers:





Tissue Viability
Observations
Documentation
Hygiene
Accountability
The Trust will continue developing e-learning for 2013/14 and work already underway includes
Corporate Essential Learning which is planned to be up and running by July 2013. Work is
also continuing with the Learning4Health platform identifying e-learning modules that can
support learners within the workplace. All of this work is allowing staff the choice of how to
achieve their learning.
2.5.6
Appraisal
Work is continuing around promoting appraisal skills with over 200 managers having gone
through the most recent phase of training. Managers are now able to use e-learning as well
as attend a face to face session. Further development will be undertaken in 2013 to support
the link with performance and values in objective setting.
2.5.7
Healthy Staff
The Trust is committed to providing support for staff to maintain their health, wellbeing and
safety. The Trust’s annual sickness rate for 2012/13 was 3.4% meaning a slight increase on
the previous year, but still leaves the Trust performing well when compared with other acute
hospitals’ sickness rates – sitting inside the lowest 10% of acute hospitals for absence rates.
Its outsourced occupational health partner, Serco, provides a comprehensive, timely and
proactive service, supporting the health and wellbeing of staff for the benefit of patients. This
includes counselling and physiotherapy services.
The joint seasonal flu vaccination
programme was a great success with more than 30% of staff receiving a vaccination.
During the year a Wellbeing Lead has been appointed from within the HR Team and The
Trust has begun working with Serco to develop a Wellbeing Strategy focusing on the
promotion of a variety of health, fitness and socio-economic wellbeing initiatives.
The management of Health and Safety is an integral part of the Trust’s risk management
strategy and is supported by the Trust’s central Governance team. Health and Safety
management therefore continues to be successfully managed by dividing the area of health
and safety into defined and manageable segments or (‘topics’), with responsibility for each
topic assigned to a specific manager within the Trust. This approach ensures that every
element of Health and Safety Legislation is appropriately covered and is in line with the
Trust’s governance arrangements.
During 2012/13 the Trust has continued to work with Serco to further develop and embed its
comprehensive programme of Health Surveillance activity. This ensures that all staff and
particularly those working in key risk areas (such as Estates), receive regular health
monitoring and support at work. Taunton and Somerset NHS Foundation Trust - Annual Report and Accounts 2012/13
31
2.5.8
Communication with Staff
The Trust uses a wide range of methods to communicate with its staff and provide them with
the opportunity to contribute to the development of its services. A weekly bulletin is issued to
staff and the Trust operates a popular staff intranet. Both of these help to keep staff up to
date in a fast changing environment. Once a month the Chief Executive hosts an open
briefing session to give all staff the opportunity to hear about key developments, changes
and/or other information of note. It also allows staff to raise any questions or concerns openly
with all the Executive Directors present and facilitates open discussion. .
Over the last year regular workforce briefings have been maintained for Trust Staff Governors.
These briefings contain information for the Governors on issues, both current and planned
that might impact upon the workforce. This provides them with the opportunity to reflect and
feedback on these issues drawing on their own experiences and those of their colleagues.
The Trust made a decision in 2011/12 to support the Governors by allowing them some
dedicated time, during working hours, to enable them to fully discharge their responsibilities.
2.5.9
Staff Engagement
During the year the Trust joined nine other trusts across the country as 'National Pioneers' to
champion adoption of ‘Listening into Action’ (LiA), a systematic approach to engaging and
empowering staff. LiA is based on:
•
•
•
•
The need for senior leaders to connect the right people around all major challenges;
Providing service teams with the opportunity to collaborate and share ideas;
Having 'permission' to get on and deliver actions which will benefit patients and staff;
Fostering a sense of collective ownership by the teams themselves for delivery of
results.
During June and July 2012 340 staff from all groups and levels across the hospital attended a
series of ‘Big Conversations’ which are an integral part of the first phase of the Listening into
Action activity. These sessions generated a significant volume of data which was carefully
analysed and a series of ‘quick win’ responses implemented to address some of the issues
raised. In addition we launched six ‘enabling projects’ to look at solving some of the more
complicated issues that affected staff across the hospital, and supported 10 individual teams
to conduct improvement projects in their own area to enable them to deliver even better care
to their patients.
The Trust developed a comprehensive set of measures against which the progress/impact of
engagement activity could be assessed. Feedback from staff involved in the LiA activity has
been almost universally positive. A second wave of team based projects has been identified
and an event was organised to share the experiences and outcomes of the first phase
projects and provide best practice guidelines for teams undertaking projects in the future.
The Trust will manage LiA activity as a core component of our existing Improvement Network
moving forward, encouraging teams to undertake locally, which will help ensure that it is
embedded quickly and effectively and has team ownership.
2.5.10 Partnership Working
During the last 12 months, the Trust has worked hard with the local Trade Unions and
professional organisations to maintain and promote effective partnership working and these
efforts are playing a positive and constructive role in ensuring a successful future for the
Trust. During the last year several major employment policies have been jointly reviewed and
32
updated and a number of organisational change processes managed effectively via
established consultative processes.
2.5.11 The Annual NHS Staff Survey
As part of the NHS National Staff Survey 2012, 850 of our staff were invited to complete
questionnaires. 438 staff responded giving a response rate for the Trust of 52%, which is 1%
lower than that for 2011, but better than the overall acute trust average of 50%.
The Annual NHS Staff Survey covers subjects such as work/life balance, teamwork,
appraisals and perceived support from managers, and allows trusts to benchmark their
employees’ attitudes and experiences with other NHS trusts. The 2012 staff survey was
structured around the four staff pledges contained in the NHS Constitution.
In the 2012 report there is a measure of staff engagement and 28 key findings (scores), which
is a lower number than in 2011 (38) due to the reduction in size of the 2012 questionnaire and
the number of questions. The results were published on 28 February 2013. They show that
11 key findings improved relative to 2011, nine showed slight deterioration, one was the same
and seven could not be compared directly due to changes in the questions.
Particularly noticeable, given the focus for LiA and the work undertaken over the past year, is
the uniformly positive feedback for the results relating to pledge four, in which we are above
average and trending positively in all five key findings. There has been a 15% increase in staff
reporting good communication between themselves and senior management and a 5%
increase in the numbers of staff who believe they are able to contribute towards
improvements at work.
Pledge 4: ‘To engage staff in decisions that affect them and the services they provide,
individually, through representative organisations and through local partnership working
arrangements. All staff will be empowered to put forward ways to deliver better and safer
services for patients and their families’.
In total we have eight results recoded as being better than average; five of which are in the
best 20% when compared to all acute trusts, 10 findings recorded as being average and 10
findings recoded as being worse than average, six of which are in the worst 20% when
compared to all acute trusts. Four issues have improved since 2011 and four have
deteriorated.
The five areas in which the Trust has performed in the best 20% are:Top Five Ranking Scores
Effective team Working
Support from immediate
managers
Percentage of staff receiving jobrelevant training, learning or
development in the last 12
months
Percentage of staff appraised in
the last 12 months
Percentage of staff reporting
good communication between
senior management and staff
National
Average
2012/13
3.72
Trust
Score
2012/2013
3.79
Trust
Score
2011/2012
3.68
Difference
3.61
3.74
3.72
+0.02
81%
81%
79%
+2%
84%
89%
84%
+5%
27%
32%
17%
+15%
33
+0.11
Those areas where the Trust has performed less well are:Bottom Six Ranking Scores
Percentage receiving health and
safety training in last 12 months
Percentage of staff witnessing
potentially harmful errors, near
misses or incidents in last month
Percentage of staff experiencing
physical violence from patients,
relatives or the public in the last
12 months
physical violence from staff in the
last 12 months
harassment, bullying or abuse
from patients, relatives or the
public in the last 12 months
Percentage of staff having
equality and diversity training
within the last 12 months
National
Average
2012/13
74%
Trust
Score
2012/13
66%
Trust
Score
2011/12
67%
Difference
34%
40%
39%
+1%
15%
17%
12%
+5%
3%
4%
1%
+3%
28%
33%
15%
+18%
55%
33%
22%
+11%
-1%
The results of the staff survey have been discussed by the Corporate Management Team and
further work has been initiated to review the detailed findings, which provide a breakdown of
response by occupational group and working area, in order to identify whether there are any
areas requiring specific interventions to support the Trust goal of providing the best possible
framework for staff to deliver the highest quality standards of care.
2.5.12 Equality and Diversity
With the support of Equality South West (ESW), the leading equality and diversity body in the
South West, the Trust conducted a range of Audit activity during 2012/13, this provided a
baseline assessment in respect of our performance against the Equality Delivery System
outcomes and a context for the development of our equality objectives and subsequent action
plan.
During the year an Access and Inclusion Group was established to oversee the development
of a vision, objectives and an associated action plan for Trust activity in the area of Equality
and Diversity. Workstream leads have been appointed and the Action and Inclusion Group will
oversee delivery of the plan.
During the year work has continued to embed the needs of vulnerable people and carers into
the work of the hospital and to enhance support for those suffering with dementia.
With specific reference to disability, the Trust is accredited with the 'two ticks' symbol which is
awarded by Job Centre Plus to employers who have made a commitment to employing,
retaining and developing the abilities of disabled staff’.
34
2.6
WORKING IN PARTNERSHIP
Taunton and Somerset NHS Foundation Trust serves a resident population of around 353,000. The
Trust also provides a range of acute services to the wider Somerset area, as well as to neighbouring
counties such as Devon and Dorset, which takes its catchment area to over 500,000.
Whilst most inpatient services are provided at Musgrove Park Hospital, the Trust also delivers
ambulatory care and outpatient services in a range of community hospitals and provides clinical
specialists into Yeovil District Hospital NHS Foundation Trust (YDH) under a Service Level Agreement
with the hospital.
2.6.1
Work with other Healthcare Providers
The Trust’s strategic vision acknowledges the critical role of working in partnership with other
organisations to enable it to achieve its aims of providing the highest quality acute services to
its population. Musgrove Park Hospital is but one part of a much larger health and social care
jigsaw. To ensure services are centred on the needs of individual patients, all the constituent
parts of the system need to work together as one. This requires close working arrangements
with other providers in the NHS and in the independent sector.
During 2012/13, more detailed discussions have been held with Royal Devon and Exeter NHS
Foundation Trust to look at the potential opportunities for greater joint working. Eight clinical
services were reviewed to test whether partnership models could improve the quality and
range of patient services provided to a larger Somerset and Devon catchment population. As
the NHS strives to deliver higher standards of care this often requires a more specialist level
of service. This can be more easily provided across a larger population by making the most
effective use of specialist skills. Further work will be progressed in 2013/14 to look at how
some of these ideas could be taken forward to enhance patient care and build on the clinical
links that already exist between the two hospitals.
Further discussions have also been held with Weston Area Health NHS Trust (Weston
Hospital) to look at how the two hospitals could work more collaboratively to provide services
to the population of North Somerset. This has focused particularly on services such as
Cardiology where some patients from Weston Hospital have been treated at Musgrove Park
Hospital rather than being seen in Bristol. During 2013/14 it is anticipated that the Trust
Development Authority will seek to identify a new provider to run Weston Hospital. Taunton
and Somerset NHS Foundation Trust will continue to work in partnership with all health and
social care organisations within the area to see whether there would be lasting benefits for
patients of Somerset and North Somerset if the Trust were to express an interest in running
Weston Hospital.
Other initiatives during 2011/12 have included Board level discussions with members of the
new Clinical Commissioning Group to discuss areas for future collaboration. This included the
need for integrated work to manage the rising elderly population and those patients with longterm conditions and manage the steady rise in the number of acute medical patients which
require treatment.
2.6.2
Social and Community Issues
As the second largest employer in Somerset, the Trust has a strategic and commercial role to
supporting partner organisations in creating economic growth. This role is recognised through
the Trust’s membership of the Project Taunton Advisory Board. The Board is a forum
consisting of representatives of major employers in the area to advise the Council on its
strategic development plans to support both commercial and residential growth.
35
Major capital schemes developed by the Trust, such as the Beacon Centre and the Jubilee
Ward Building, bring benefits to the Somerset community, including employment
opportunities.
The Trust continues to enjoy close working relationships with other local organisations, such
as Somerset County Council and Somerset College. The Trust is currently working in
partnership with the College to seek new residential accommodation for the Bristol Medical
School students on placement at Musgrove Park Hospital.
In previous years there has been a particular focus on improving the representation of
younger Foundation Trust members through links with a local college. The focus for 2013/14
is to increase engagement and to give a voice to younger members.
The Governors are responsible for regularly feeding back information about the Trust’s vision
and performance to members and, in the case of nominated governors, to the partner
organisations they represent, such as the County Council, District Council and Universities.
The Governors continue to ensure that the Trust maintains good links to the community in
these key partnership organisations. The work of the Governors and their engagement with
the wider membership is described in further detail in Section 5.
The Trust has continued to sponsor clinical teams to visit a hospital in Zanzibar, allowing staff
to pass on their expertise and training, and also to learn from the communities there. The
project is funded through Charitable Funds provided for staff development. Particularly
successful visits took place in 2012 with teams from A&E and medical imaging following up
initiatives started the previous year.
For over 20 years Art for Life has been working to improve the experience of patients and staff
at Musgrove Park. The programme is based on clear evidence that art in hospitals can make
a real difference to patient care, by creating a calm environment which can reduce stress
levels, relieve pain and anxiety, improve the communication of health messages, boost
morale and, ultimately, reduce the length of stay in hospital. Therefore creating an uplifting
environment has been a priority and it is estimated that Art for Life has over the years worked
to improve over 70% of all patient areas, as well as 80% of the public circulation areas. As
part of their programme Art for Life offer six music concerts and six temporary exhibitions in
the Musgrove Gallery. Creative activities for patients on the wards is also an increasingly
important part of our annual programme.
Over the past year Art for Life has focused on a number of key projects and priorities. These
have been:

The Jubilee Building. We have secured photographic artworks for each of the 112
single rooms, developed and tested the technical design of The Murmuration (a
signature artwork for the buildings towers), and the Eisenhower Tree has been felled,
sliced and wooden panels are being created for each of the three floors of the
building.

The Central Concourse. Lead artist Chris Tipping has worked on designs for a
major screen which separates pedestrian flows and creates privacy for patients as
they move through the space. The screen will be covered with a strong textile
cladding printed with designs inspired by the history of the hospital.

Dementia. Art for Life continues to explore the role art can play in helping patients to
feel more at ease in their surroundings and express themselves. New Quiet spaces
36
have been created on Wordsworth Ward and artworks have been used to create
more dementia friendly bays on Elliot Ward. Creative sessions at bedsides have
been trialled and a new programme of sessions with a storyteller, singer and visual
artist are soon to start.

End of Life. Art for Life has been working with staff to explore ways to improve
spaces such as quiet rooms in which families and loved ones may receive bad news,
enhanced side rooms for end of life care and refurbished viewing facilities in the
mortuary.

The Old Building. Projects have improved Parkside, the Surgical Admissions
Lounge, Surgical Admissions Unit, The Children’s Unit, Colposcopy and new artworks
were installed along the length of the corridor.

Celebrating 70 years of Musgrove Park Hospital. ‘Sensing Our Past’, a Heritage
Lottery Funded project, has enabled Art for Life to create an archive and book of
historic photographs, develop designs for artworks inspired by the history of the
hospital for the Jubilee Building and Central Concourse and explore how
reminiscence can help patients with dementia share their memories.
37
3.
CORPORATE GOVERNANCE AND DIRECTORS’
INFORMATION
Taunton and Somerset NHS Foundation Trust is a public benefit corporation established under the
Health and Social Care (Community Health Standards) Act 2003 - which has been replaced by the
National Health Service Act 2006.
The Board of Directors of the Trust attaches great importance to ensuring that the Trust operates high
standards of governance and seeks to observe the principles set out in the Monitor NHS Foundation
Trust Code of Governance.
The Board is responsible for the strategic planning, culture and performance management of the Trust
and for ensuring proper standards of corporate governance are maintained. The Executive Directors
are responsible for the day to day activities of the Trust and for operating within the Trust’s Scheme of
Delegation, which sets out the decisions reserved for the Board and its sub-committees and directors,
and decisions delegated to management. The Board overall accounts for the performance of the
hospital and consults on its future strategy with its members through the Council of Governors
(‘COG’).
The role of the COG is to influence the strategic direction of the Trust to take account of the needs
and views of the members, to hold the Trust Board (and, in particular, the non-executive directors) to
account on its performance, to develop a representative, diverse and engaged membership and to
make an improvement to the patient experience. In addition, it carries out its statutory duties,
including the appointment of the Chairman and non-executive directors of the Trust and appointment
of the external auditor.
3.1
Governance Structure
The Trust’s Constitution and terms of reference for the Board’s committees were reviewed in
2012/13 to ensure they continue to comply with best practice. Work is in progress to revise
the Trust’s Constitution in line with provisions of the Health & Social Care Act 2012 coming
into force from April 2013.
3.2
Chairman
The Chairman of the Trust is Rosalinde Wyke, a non-executive director who has no conflicting
relationships. Under the terms of her appointment, Rosalinde is required to devote three days
per week to the affairs of the Trust. Details of the Chairman’s other commitments are listed on
page 6. The Board remains confident that she has sufficient time to meet her obligations to
the Trust.
3.3
Vice-Chair
The Vice-Chair is Chris Harvey, who has been elected to this position by the Council of
Governors on the recommendation of the Board, for a term of one year, which ends in
December 2013. Chris deputises for the Chairman at Board and other meetings (internally
and externally) if the Chairman is unable to attend.
3.4
Senior Independent Director
Gill McComas is the Trust’s Senior Independent Director, having been elected to this position
by the Board, for a term of one year, which ends in December 2013. Part of the role of the
38
Senior Independent Director is to provide another route for communication with governors if
they feel unable for any reason, to raise a particular concern through the Chairman.
3.5
Board of Directors (“the Trust Board”)
The Trust Board currently comprises seven non-executive directors, inclusive of the
Chairman, all of whom are considered by the Board to be independent. There are six
executive directors, all of whom hold permanent NHS contracts, subject to NHS Terms and
Conditions.
The Board, having considered its composition to fulfill its functions and remain within Monitor’s
Terms of Authorisation, confirms that it is appropriately composed. Two non-executive
directors have been appointed (March 2013), one of which is in shadow form until 1 April
2013.
The Director of Nursing and Governance resigned from his post in February 2013 and an
Acting Director of Nursing has been appointed until a permanent appointment has been
made.
The Board holds a Register of Interests declared by directors. These interests include
directorships of companies with whom the Trust could do business, together with other
interests which the directors believe might be relevant to their Board membership. The Trust
has not entered into any material transaction with a company for which a declaration has been
made. The Register of Interests is available from the Trust Secretary, who may be contacted
by telephone on 01823 342511.
3.6
Appointment re-election and the Nomination and Remuneration Committee
The Chairman, in consultation with the directors, is 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 Nomination and Remuneration Committee,
which comprises the Chairman and the non-executive directors, supported by the Chief
Executive, who will produce a job description, instruct recruitment consultants as necessary,
short-list and interview candidates. If the vacancy is for a non-executive director, the Council
of Governors convenes a Nomination Working Group. The Nomination Working Group then
instructs recruitment consultants if required, short-lists and interviews candidates, then
recommends the selected candidates to the Council of Governors for appointment.
The Trust’s Constitution provides that non-executive directors are appointed initially (subject
to an open recruitment process) for a four year term of office. They may be re-appointed for a
second term of three years on an uncontested basis, subject to completion of a satisfactory
performance appraisal. Similarly, the Chairman is appointed initially (subject to an open
recruitment process) for a four year term of office and may be re-appointed for a second term
of three years on an uncontested basis. Re-appointment of non-executive directors (including
the Chairman) for a third term is subject to open competition and limited to a term of office of
two years.
The Chairman was re-appointed on 1 August 2010 via an open recruitment process for a
second term of office of four years. This was in accordance with the terms of the Trust’s
Constitution, which was subsequently revised later in 2010, to reflect the new process outlined
above.
The Chairman, other non-executive directors and Chief Executive (except in the case of the
appointment of a new Chief Executive), are responsible for deciding the appointment of
39
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 Council of Governors.
3.7
Attendance record for the year as at 31 March 2013
The table on page 43 sets out the Trust Board and Board sub-committee meetings held
during 2012/13, showing the attendance of executive and non-executive directors throughout
the year.
3.8
Trust Auditors
PricewaterhouseCoopers LLP (PwC), was appointed as the Trust’s external auditor for an
initial term of three years commencing 1 April 2009. In accordance with the terms of the
external auditor’s appointment, the Council of Governors approved an extension of PwC’s
contract for a further two years, commencing 1 April 2012, based on a review and
recommendation by the Audit Committee.
During 2012/13, internal audit services have been provided by RSM Tenon Limited on a
shared service arrangement with NHS Somerset Primary Care Trust, Somerset Partnership
NHS Foundation Trust and Yeovil District Hospital NHS Foundation Trust. A procurement
process to consider the appointment of Internal Auditors from 2013/14 is currently in progress
with the appointment of new Internal Auditors to be shortly confirmed.
3.9
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 committee primarily utilises the work of the internal and external auditors. The
Audit Committee also takes assurance from the views of other external agencies about the
Trust’s procedures and from the Governance Committee.
Gavin Gracie has been chair of the Audit Committee since 1 May 2011. Chris Harvey
continues to be a member of the Audit Committee. Both Chris Harvey and Gavin Gracie have
significant financial experience and are qualified accountants. Stephen Harrison, who joined
the Board as a non-executive director on 1 March 2013 (shadow non-executive until 1 April
2013), is also a member of the Audit Committee. Stephen was the Chairman of a cluster of
PCTs responsible for health services across Bristol, North Somerset and South
Gloucestershire.
The audit of the Trust’s Annual Report and Accounts is discussed by the Audit Committee
with the external auditor before the Board approves and signs them.
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 external auditor.
The Audit Committee agrees the schedule of internal audit reviews each year and it receives
the reports and follows-up on the issues raised. Where major issues are identified, managers
who are responsible for the areas reviewed are asked to attend the Audit Committee meeting
and report on the steps taken to avoid similar issues arising again. The Audit Committee
receives and monitors the policies and procedures associated with countering fraud and
corruption. An independent local counter-fraud service produces a quarterly counter-fraud
40
progress report, giving updates on both reactive and pro-active work undertaken in the Trust
and assists the Trust in ensuring it has policies that are compliant with all relevant regulations.
The Audit Committee reviews and monitors the external auditor’s independence and
objectivity at least once a year. The Audit Committee also reviews any non-audit work carried
out by the external auditor to ensure that the objectivity and independence of the external
auditor, is not impaired. However, there was no significant non-audit work carried out by the
external auditor during 2012/13.
3.10
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 the individual directors. This 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 manage the Trust effectively.
During 2012/13 the Board has undertaken performance evaluation in respect of Board
meetings through discussion. In terms of individual appraisals, the Chairman undertakes the
appraisal of the Chief Executive and the non-executive directors, having sought feedback
from the other 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 and from the Governors. The process for
the review of the Chairman and the non-executive directors has been approved by the
Remuneration Working Group of the Council of Governors, which then confirms completion of
the process to the Council of Governors.
The Chief Executive discusses the executive directors’ appraisals with the Chairman and
reports their outcome to the Remuneration Committee.
Opportunities are provided for directors to attend conferences and training, as appropriate, to
strengthen their skills to enable them to discharge their duties. Training for executive
directors is arranged in accordance with individual needs and responsibilities, as well as being
part of whole Board development and training.
The overall result of the performance evaluation process in respect of the year to 31 March
2013 was that the Board collectively, and the Directors individually, were deemed to have
performed satisfactorily.
3.11
Trust Secretary
The Board has direct access to the advice and services of the Trust 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 and
advising the Board through the Chairman on all corporate governance matters.
41
3.12
Statement of Compliance with the NHS Foundation Trust Code of Governance
The Trust Board considers that it was compliant with the provisions of the NHS Foundation
Trust Code of Governance with the exception of the following code provisions:
C2.2
Non-executive directors are appointed for an initial term of four years rather than
three. The Governors proposed a longer term on the basis that the Constitution
provided for open competition and the four year term provided better value. The
Constitution was changed during 2010/11 to enable reappointment for a second term
without the need for open competition, although a second term is restricted to a
duration of three years.
A.3.2
Currently, one half of the Board, including, rather than excluding, the Chairman,
comprises non-executive directors determined by the Board to be independent.
42
Membership of
Board and SubCommittees at
31 03 12
Position
Trust
Board
Policy &
Strategy
Group
Performance
& Assurance
Committee
Governance
Committee
Audit
Committee
Treasury &
Investment
Committee
Charitable
Funds
Committee
Nomination &
Remuneration
Committee
√
**
√
C
√
C
C
(Nomination)
√
NEDs
Rosalinde Wyke
Chairman
C
C
C
Chris Harvey
Non-Executive Director, ViceChair
Non-Executive Director – (from
01 04 13)
Non-Executive Director, SID
(Vice-Chair to 31 12 11)
Non-Executive Director (from
01 03 13)
√
√
√
√
√
√
√
√
√
√
C
√
√
√
√
√
√
Non-Executive Director (to 31
01 13)
√
√
√
√
√
√
√
√
Jo Cubbon
Chief Executive
√
√
√
√
Peter Lewis
√
√
√
√
Stephen Harrison
Gill McComas
Brian Perowne
Gavin Gracie
Dr Elizabeth Driver –
Derek Manuel
√
√
√
√
√
C
C
(Remuneration)
√
√
√
√
EXECUTIVES
**
*
√
√
(as of Feb
2013)
David Allwright
√
√
√
Colin Close
Director of Corporate Planning
& Performance
Medical Director
√
√
√
Simon Wombwell
√
√
√
Director of Nursing &
√
Governance (to 15 02 13)
Carol Dight
Acting Director of Nursing (from
√
23 02 13)
C = Chair of the Committee
* = By invitation
** Annually
√
√
√
√
√
√
Greg Dix
√
√
√
√
√
43
√
Trust Board and Sub-Committee Attendance 2012/13
Position
Trust
Board
Policy &
Strategy
Group
Performance
& Assurance
Committee
Governance
Committee
Audit
Committee
Treasury &
Investment
Committee
Charitable
Funds
Committee
Nomination/
Remuneration
Committee
Number of eligible meetings attended in 2012/13
NEDs
Rosalinde Wyke
Chairman
5 out of 5
6 out of 6
6 out of 6
5 out of 5
1 out of 1
5 out of 5
3 out of 3
5 out of 5
Gill McComas
SID –
Vice-Chair - Non-Executive
Director
5 out of 5
6 out of 6
6 out of 6
4 out of 5
-
-
2 out of 3
5 out of 5
5 out of 5
6 out of 6
6 out of 6
-
4 out of 4
5 out of 5
1 out of 1
5 out of 5
1 out of 1
-
-
-
-
-
-
1 out of 1
Chris Harvey
Brian Perowne – from
01 03 13
Stephen Harrison –
from 01 04 13
(Shadow NED from 13 02
13)
-
1 out of 1
-
1 out of 1
-
-
-
2 out of 2
5 out of 5
6 out of 6
6 out of 6
-
3 out of 4
-
-
5 out of 5
3 out of 4
5 out of 6
5 out of 6
4 out of 4
1 out of 3
-
1 out of 1
2 out of 3
5 out of 5
6 out of 6
6 out of 6
5 out of 5
-
4 out of 5
-
5 out of 5
Jo Cubbon
Chief Executive
5 out of 5
6 out of 6
6 out of 6
4 out of 5
1 out of 1
5 out of 5
-
5 out of 5
Peter Lewis
5 out of 5
6 out of 6
6 out of 6
4 out of 5
1 out of 1
-
3 out of 3
-
David Allwright
Director of Corporate
Planning & Performance
Director of Nursing &
Governance
Acting Director of Nursing
4 out of 5
6 out of 6
6 out of 6
-
-
5 out of 5
2 out of 3
-
4 out of 4
6 out of 6
6 out of 6
3 out of 5
3 out of 3
-
-
-
1 out of 1
-
-
-
-
-
-
-
Medical Director
4 out of 5
6 out of 6
6 out of 6
3 out of 5
-
-
-
-
5 out of 5
6 out of 6
6 out of 6
-
4 out of 4
4 out of 5
3 out of 3
-
Gavin Gracie
Dr Elizabeth Driver –
to 31 01 13
Derek Manuel
EXECUTIVES
Greg Dix – to 15 02 13
Carol Dight – from 23
02 13
Colin Close
Simon Wombwell
44
4.
REMUNERATION REPORT
4.1
Nomination and Remuneration Committee (Trust Board)
The Nomination and Remuneration Committee comprises the non-executive directors and
determines the level of remuneration, terms of service for the Chief Executive and other
Executive Directors. It also supports the work of the Chairman in assessing the size,
structure and skill requirements of the Board as described in Section 3.
In determining pay, the Nomination and Remuneration Committee seeks to strike a balance
between setting pay at a level sufficient to recruit, retain and reward individuals of a high
caliber and ensuring best value in the use of public finances.
The pay of all directors and senior managers was frozen for 2012/13 and 2011/12. Rates of
remuneration for executive directors who have been appointed since January 2010 have
been determined largely by reference to the median pay rates of comparable roles at other
foundation trusts, taking into account experience and the size and nature of the organisation.
The Nomination and Remuneration Committee also takes into account the rates of pay of the
Trust’s other employees to ensure that pay rates of directors are not disproportionate to the
rates payable to other grades, taking into account the additional responsibilities they carry.
Executive members of the Board are employed on contracts with no fixed or specified term,
save for the Medical Director, who is subject to a three year fixed term in respect of his
executive role. Notice periods for executive members of the Board are set at six months. No
provision is made for additional termination payments, and the Trust can confirm that no
significant awards were made to past senior managers during 2012/13.
The Nomination and Remuneration Committee met five times during 2012/13. On all
occasions, the Trust Secretary was in attendance to take minutes. The Chief Executive
attended all of the meetings for the purpose of providing further detail on the executive posts
being discussed.
Attendance at meetings was as follows:
Rosalinde Wyke
Chris Harvey
Gill McComas
Gavin Gracie
Derek Manuel
Elizabeth Driver (to 31.1.13)
Stephen Harrison (from 13.2.13)
Brian Perowne (from 1.3.13)
5 out of 5
5 out of 5
5 out of 5
5 out of 5
5 out of 5
2 out of 3
2 out of 2
1 out of 1
See pages 47 and 48 for salary and pension entitlements for senior managers.
The Nomination and Remuneration Committee is chaired by the Chairman in respect of all its
responsibilities for determining remuneration rates and terms for senior managers, with the
exception of executive directors which is chaired by the Senior Independent Director, as
recommended by Monitor’s Code of Governance.
4.2
Remuneration Working Group (Council of Governors)
The Council of Governors Remuneration Working Group is responsible for the remuneration
and terms of employment for the non-executive directors of the Trust Board. The group
45
agreed the Chairman’s salary as part of the recruitment process in April 2010, based on the
2009 median rate payable to Foundation Trust Chairman. At the time of reappointment
following a full recruitment process the Chairman elected not to take her full salary. From 1
April 2012 the Chairman is now paid her full salary.
Non-executive directors who have been appointed since 2009/10 receive pay in accordance
with the prevailing rate for existing non-executive directors.
Non-executive directors serve a maximum tenure of nine years, subject to an initial four year
term, a second three-year term, plus a further two year term, subject to open competition.
Non-executive directors are not required to serve a period of notice on leaving office.
4.3
Audited
Reporting bodies are required to disclose the relationship between the remuneration of the
highest-paid director in their organisation and the median remuneration of the organisation’s
workforce.
The banded remuneration of the highest-paid director in Taunton and Somerset NHS
Foundation Trust in the financial year 2012/13 was £165,000 to £170,000 (2011/12:
£165,000 to £170,000). This was 6.1 times (2011/12: 6.8) the median remuneration of the
workforce, which was £27,379 (2011/12: £24,554).
In 2012/14, 7 employees received remuneration in excess of the highest-paid director
(2012/13: 5). Remuneration ranged from £167,000 to £235,000 (2011/12: £179,000 to
£180,000).
Total remuneration includes salary, but does not include employer pension contributions, the
cash equivalent transfer value of pensions and overtime.
46
Salary and Pension entitlements of senior managers - Audited
A) Salaries and Allowances
Salary
Name and Title
(Bands of
£5000)
£000
Executive Directors
Ms J Cubbon Chief Executive
Mr P Lewis Deputy Chief Executive
Mr D Allwright Director of Corporate Planning and Performance
Mr S Wombwell, Director of Finance & IT
1
Dr Colin Close, Medical Director (from 01/10/11)*
Mr G Dix, Director of Governance and Nursing (to 15/02/13)
165-170
120 - 125
110 - 115
115-120
10 - 15
85-90
2012-13
Other
Remuneration
Benefits in
Kind
Salary
2011-12
Other
Remuneration
(Bands of £5000)
£000
Rounded to the
nearest £100
(Bands of
£5000)
£000
(Bands of
£5000)
£000
5,600
0
0
0
0
0
165 - 170
120 - 125
110 - 115
115 - 120
10 - 15
85 - 90
165-170
Mrs C Dight, Interim Director of Nursing (from 23/02/13)
10-15
0
Non-Executive Directors
Ms A R Wyke Chair
Mr D Manuel
Dr E Driver (to 31/01/13)
Mr C Harvey, Vice-Chair
Mr G Gracie
Ms G McComas, Senior Independent Director
Mr B Perowne (from 01/03/13)
40 - 45
10-15
10-15
10 - 15
15 - 20
10 - 15
0-5
5,500
1,100
0
1,500
1,800
2,200
0
0-5
0
Mr S Harrison (shadow from 13/02/13)
1
* Other Remuneration is for clinical employment with the Trust.
Benefits in Kind
Rounded to the
nearest £100
80-85
40 - 45
5 - 10
5 - 10
10 - 15
15 - 20
10 - 15
The benefits in kind received by the Non-Executives are for Taxable mileage (home to base) where the Trust meets this obligation and the Executive Directors are for lease car
and taxable mileage.
47
5,500
100
0
100
0
0
4,700
600
100
1,600
1,500
1,300
Salary and Pension entitlements of senior managers continued - Audited
B) Pension Benefits
Real increase
in pension at
age 60
Real increase
in lump sum at
age 60
Total accrued
pension at age
60 at 31 March
2013
Lump sum at
age 60 related
to accrued
pension at 31
March 2013
Cash
Equivalent
Transfer Value
at 31 March
2013
Cash
Equivalent
Transfer Value
at 31 March
2012
Real Increase
in Cash
Equivalent
Transfer Value
- funded by
employer
(bands of
£2500)
£000
(bands of
£2500)
£000
(bands of
£5000)
£000
(bands of
£5000)
£000
To nearest
£1000
To nearest
£1000
To nearest
£1000
Ms J Cubbon Chief Executive
- 2,500-0
- 2,500-0
45,001 - 50,000
Mr P Lewis Deputy Chief Executive
- 2,500-0
- 2,500-0
35,001 - 40,000
145,001150,000
105,001110,000
Mr D Allwright Director of Corporate Planning and
Performance
- 2,500-0
- 2,500-0
35,001 - 40,000
0-2,500
2,501 - 5,000
Name and Title
Employers
Contribution to
Stakeholder
Pension
To nearest £100
Executive Directors
Mr G Dix Director of Governance and Nursing (to
15/02/13)
950
883
12
0
513
479
5
0
110,001115,000
655
611
7
0
15,001 - 20,000
45,001 - 50,000
237
195
19
0
Mrs C Dight, Interim Director of Governance & Nursing
0-2,500
0-2,500
15,001 - 20,000
50,001 - 55,000
316
253
4
0
Mr S Wombwell Director of Finance & IT
0 - 2,500
2,501 – 5,000
10,001 - 15,000
224
195
11
0
Dr C Close, Medical Director
0 - 2,500
5,001-7,500
55,001 - 60,000
40,001 - 45000
175,001180,000
1,251
1,068
71
0
As non-executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for non-executive members.
A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member's accrued
benefits and any contingent spouse's pension payable from the scheme. A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits in another pension scheme or arrangement when
the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total
membership of the pension scheme, not just their service in a senior capacity to which the disclosure applies. The CETV figures, and from 2004-05 the other pension details, include the value of any pension benefits in
another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional
years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.
Real Increase in CETV - This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the
value of any benefits transferred from another pension scheme or arrangement) and uses common market valuation factors for the start and end of the period.
Signed
Jo Cubbon, Chief Executive
Date: 29 05 13
48
5. COUNCIL OF GOVERNORS AND MEMBERSHIP
The Council of Governors is made up of elected and nominated Governors who provide an important
link between the hospital, local people and key organisations, sharing information and views that can
be used to develop and improve hospital services.
The Council consists of 27 Governors:

15 publicly elected Governors from four constituencies:
–
–
Taunton: The area represented by Taunton Deane Borough Council – 5 Governors
West Somerset: The area represented by West Somerset District Council and
Sedgemoor District Council – 5 Governors
East Somerset: The area represented by Mendip District Council and South Somerset
District Council – 4 Governors
Rest of England: Anywhere in England not included in the above areas – 1 Governor
–
–

Five Staff Governors elected by self-nomination and constituency voting, representing a
minimum of 3 out of the following 5 staff groups:
–
–
–
–
–
Medical and Dental
Nursing and Midwifery
Hotel and Estates Services
Clerical, Administrative and Managerial
Allied Professionals, Scientific and Technical
Seven Partnership Governors appointed by partnership or stakeholder organisations.
5.1
Role of Governors
The Council of Governors is responsible for representing the interests of the Trust’s members
and its partner organisations in the local health economy. Governors have a statutory duty to
hold non-executive directors to account for the performance of the board of directors and can
require directors to attend their meetings. Governors are also responsible for regularly
feeding back information about the Trust (for example about its vision and its performance) to
members and, in the case of nominated Governors, to the stakeholder organisations they
represent. It is also the Governors' responsibility to represent their members' interests,
particularly in relation to the strategic direction of the Trust.
During 2012/13 the Council of Governors has carried out the following statutory duties:

Approved the appointment of the Trust Board’s Vice-Chair;

Noted the appointment of the Senior Independent Director;

Approved changes to the Trust Constitution;

Approved the appointment of two new non-executive directors; and

Considered the Trust’s annual plan, received the auditor’s reports and annual report
and accounts;

Responded to consultation by the Board of Directors on the development of forward
plans for the Trust;
In addition the Council of Governors has:

been consulted on the future plans of the Trust and contributed to the planning cycle;
49


influenced the development of the Trust’s Quality Accounts, including selecting the
Quality Account priorities for 2013/14;
ratified the appointment of the Lead Governor.
There are three Governor-led sub-groups of the Council of Governors who take the lead in
relation to areas of work where more detail is required. They provide reports and
recommendations, as appropriate, for consideration by the Council of Governors.
The
working groups have an executive lead who works with the Governors to plan agendas and
implement agreed actions at these meetings. The working groups meet on average, four
times a year. The Trust’s Chairman is extensively involved with the leadership of the working
groups of the Council of Governors.
In addition to the statutory duties detailed above, the Governors have, via the working groups,
considered a variety of topics which they have an opportunity to influence. In 2012/13 these
covered:







Patient experience;
Membership strategy;
Quality Account priorities for 2013/14;
Engagement with staff members;
Training and development needs of Governors;
Communication with members – Annual Members’ Meeting, Medicine for Members’
and Constituency meetings;
A review of the Constitution to ensure it accurately reflects the environment in which
the Trust operates.
Expenses incurred by Governors during 2012/13 are as follows:
Name
Tony Wood
Mike Bickerstaff
Kate Forsyth
Jim Mochnacz
Wendy Darch
Total
Amount
£679.40
£812.20
£152.70
£538.79
£35.10
£2,218.19
All other Governors received nil expenses for 2012/13.
5.2
Governor Resignations and Elections April 2012 to March 2013
In accordance with its Constitution the Trust uses a method of Single Transferable Voting
(STV) for all elections. STV relies on preferential voting in multi-member constituencies.
Each voter gets one vote, which may be transferred from their first-preference to their secondpreference and so on, as necessary. Candidates do not need a majority of votes to be
elected, just a known 'quota', or share of the votes, determined by the size of the electorate
and the number of positions to be filled. Electoral Reform Services was appointed to oversee
elections in 2012.
Governor elections were held during November 2012 and all seats were contested. The
overall turnout out across all four constituencies was approximately 22%, which is the national
average.
50
A full list of Governors who were in post on 31 March 2013 and details of changes during the
year is set out on pages 54 to 55, together with details of the number of Council of Governors
meetings attended by each Governor during 2012/13.
5.3
Register of Interest
A register of Governors’ interests is maintained. A copy of the latest version submitted to the
Council of Governors is available from the Trust’s Governor Support Manager who may be
contacted on 01823 342051.
5.4
Understanding the Views of Governors and Members
Throughout the year the executive and non-executive directors have used a variety of
methods to ensure that they take account of, and understand, the views expressed by
Governors and Trust members.
The Chair of the Trust Board is also the Chair of the Council of Governors and is the principal
conduit between the two bodies. The Council of Governors meets in public five times a year
and also holds an Annual Members’ meeting for FT members.
The Chief Executive attends all meetings and presents an integrated management report on
the Trust’s performance. Governors have the opportunity to express their views and raise any
concerns for the Chief Executive and members of the executive team to respond to. Minutes
of the meeting are shared with the Trust Board who action any points relevant to their areas.
Other Board members, including the non-executive directors, attend the majority of the
Council of Governors’ meetings and participate in discussions and respond to any questions
as appropriate
5.5 Engagement with Governors and Members
Outside of the Council of Governors’ meetings, Governors are supported by the Trust in a
number of important ways to help facilitate effective engagement between the Board and
Governors. The Trust's Chairman plays an active role in ensuring that Governors receive
appropriate training and are well supported. Training and development are essential for
Governors to understand their role and responsibilities.
The Foundation Trust Network
(FTN) has been commissioned to develop a Governor Development Programme that will
focus on induction, core skills and specialist skills. The Trust’s Chairman sits on the Steering
Committee and will be involved in the development of this programme.
Governors also attend an annual 'development day', where they are provided with updated
information about the role of the Governor and given the opportunity to take part in
discussions, which reinforces earlier training. Governors are also kept up-to-date with
information about the Trust via a newsletter for Governors, issued approximately every two to
three months. Members are kept up-to-date with news and information about the hospital in
the Trust’s “Musgrove Matters” newsletter which encourages feedback and comment from
members, via a designated email address and via the Governor Support Manager.
The Trust's Governors also participate in the South West Governors Exchange Network
(SWGEN), co-hosted by the Trust and Somerset Partnership NHS Foundation Trust. The
SWGEN meets three times a year and explores topical issues, usually focused on
governance, within the NHS and the wider healthcare sector. Governors receive
presentations on areas of clinical excellence, innovation and new service development that
reflect the on-going work throughout the South West. The meetings also provide an
opportunity for Governors to meet and discuss ideas with fellow governors from other trusts in
51
the south west. The Medicine for Members meetings themselves also represent an important
means by which the Trust engages with its members. Clinicians have spoken on a variety of
topics at these meetings during 2012/13, including ‘A history of radiotherapy’, ‘Blood pressure,
silent killer’ and ‘diabetes, the epidemic’.
The Trust held constituency meetings in conjunction with the Trust’s “Medicine for Members”
meetings. These meetings give Governors’ an opportunity to listen to members’ views, which
they can later feedback to the Council of Governors for discussion or action as appropriate.
The fifth Annual Members’ Meeting of Taunton and Somerset NHS Foundation Trust took
place on Wednesday 26 September 2012; the meeting was open to all Trust members and
over 180 people attended. The overall purpose of the meeting is to communicate key
information about the Trust’s performance to members, ensuring that they are fully briefed and
aware of the main business of the Trust and in a position to pass this on to other members of
the community.
At the meeting in September 2012, members, Governors, staff and representatives of local
Government and Health Organisations heard from Rosalinde Wyke (Chairman) and Jo
Cubbon (Chief Executive) who gave a presentation on “Piloting Through Rough Seas”. The
audience also heard from Paul Mackey, Consultant, who delivered the main plenary
presentation on enhanced recovery in colorectal surgery. There was a lively question time
slot chaired by the BBC’s local reporter Clinton Rogers and members were invited to ask a
panel of the Trust’s senior management team questions on topics that were important to them.
There were a also a number of exhibition stands providing advice from hospital staff and other
health professionals and groups associated with the hospital on how to stay “fit and healthy”.
The Member-Only web pages on the Trust’s website allows members to access the latest
news, to view Board papers and minutes from previous meetings, and to contact their
Governors. The Trust is developing a new website and Governors and FT Members
participated in a web site advisory group and provided feedback on the development and
design of the Trust’s new website.
The Musgrove Awards for Tremendous Achievement (MAFTA’s) were held in 2012. This
award ceremony recognizes people who have made a real difference to Musgrove Park
Hospital, rewarding educational achievements, loyalty to the hospital, innovation, commitment
and dedication. The Chairs of the Council of Governor Working Groups were invited to judge
a number of the categories.
Governors attended the Musgrove Park Hospitals’ thank you to over 100 volunteers at its
annual tea party at the Taunton Flower Show.
Foundation Trust members may contact Governors via a dedicated e-mail address at
governors@tst.nhs.uk, through the website at www.tsft.nhs.uk or via Kerry Laugharne,
Governor Support Manager, on 01823 342051.
52
Membership as at 31 March 2013
Public Membership
Constituency
Taunton
West Somerset
East Somerset
Rest of England
Number of
Members
31.3.13
Number of
Members
31.3.12
4768
2866
1885
1317
4885
2952
1945
1243
% increase over
year (absolute
figures in
brackets)
-2.4% (117)
-2.9% (86)
-3.1% (60)
5.9% 74
%
Population
that are
Members
4.2%
1.9%
2.1%
N/A
Staff Membership
Constituency
*
Medical & Dental
Nursing & Midwifery
Hotel & Estate Services
Admin, Clerical and
Managerial
Allied Professionals, Scientific
& Technical
5.6
Number of
Members
31.3.13
Number of
Members
31.3.12
% increase over
year (absolute
figures in
brackets)
%
Population
that are
Members
498
471
5.7% (27)
95%
1404
1366
2.8% (38)
68%
378
345
9.6% ( 33)
72%
806
776
3.9% (31)
74%
346
381
-9.2% (35)
65%
Actions to Increase and Develop Membership in 2013/14
In previous years there has been particular focus on improving the representation of younger
members through its links with a local college of further education. Students have been
involved with projects to recruit new members on behalf of the Trust, putting forward
proposals, producing a business plan and identifying the resources needed to make the
project successful. The focus for 2013/14 is to increase engagement and communication with
younger members.
The public membership figure for 2012/13 is just under 11,000 against a target of 10,000. The
focus for the forthcoming year continues to be on increased engagement and communication
with the core membership, rather than increasing the rate of recruitment.
Elected Governors – Public Constituency
NAME
Leonard Daniels1
Anne Elder
2
Hazel Hancock
Jeanette Keech
Ron Powell
Ian Ramus
Steve Barham
Mike Bickersteth
CONSTITUENCY
Taunton Deane
Taunton Deane
Taunton Deane
Taunton Deane
Taunton Deane
Taunton Deane
West Somerset
West Somerset
DATE ELECTED
TERM OF
OFFICE
Jan 2013
Dec 2010
Dec 2010
Dec 2012
Dec 2010
Dec 2012
Dec 2009
Dec 2012
1 year
3 years
3 years
3 years
3 years
3 years
3 years
3 years
53
ATTENDANCE
AT COUNCIL
OF
GOVERNOR
MEETINGS
4 from 4
4 from 5
4 from 4
3 from 5
5 from 5
2 from 2
2 from 5
4 from 5
Judith Goodchild
4
Stephanie Oliver
Jonathan SeckerWalker
Wendy Darch
Kate Forsyth
Elizabeth Parry
Jim Mochnacz
Ronald Wood
Basil Brunning3
West Somerset
West Somerset
West Somerset
Dec 2012
Dec 2010
Dec 2010
3 years
3 years
3 years
3 from 5
1 from 5
4 from 5
West Somerset
East Somerset
East Somerset
East Somerset
East Somerset
Rest of England
Dec 2012
Dec 2010
Dec 2010
Dec 2012
Dec 2012
Dec 2010
3 years
3 years
3 years
3 years
3 years
3 years
2 from 2
5 from 5
3 from 5
2 from 5
5 from 5
0 from 5
The Trust held elections in the Taunton Deane, East and West Somerset public constituencies
in November 2012. Taunton Deane, Jeanette Keech was re-elected for a second term and
Ian Ramus was elected for the first time. West Somerset, Mike Bickersteth was re-elected for
a third and final term and Wendy Darch was elected for the first time. East Somerset, Jim
Mochnacz was re-elected for a second term and Tony Wood was re-elected for a third and
final term.
1
Leonard Daniels (Taunton Deane) was appointed for a 1 year period to complete the term of
office of Taunton Deane Governor, 2Hazel Hancock, who resigned in January 2013 following a
move out of the area. Hazel’s term of office was due to expire in November 2013. Where a
vacancy arises amongst the elected Governors. There is provision in the Trust Constitution
to invite the next highest polling candidate for that seat at the most recent elections to fill the
vacancy until the next annual election.
3
Unfortunately due to ill health Basil Brunning has not been well enough to attend any of the
Council of Governor meetings in 2012/13. The Council of Governors were content that due to
the circumstances Basil would continue to the end of his term of office in November 2013.
4
Following a period of convalescence Stephanie Oliver is looking forward to resuming her
governor role in 2013.
Elected Governors – Staff Constituency
NAME
Dr Tarun Solanki
Dr Andy Tandy
Angus Maccormick
Dr Timothy Zhilka
Cathy Phillips
Trish Hilton5
CONSTITUENCY
Medical & Dental
Medical & Dental
Nursing and
Midwifery
Medical & Dental
Allied Professionals,
Scientific and
technical
DATE ELECTED
TERM OF
OFFICE
Dec 2012
Dec 2009
Dec 2012
3 Years
3 years
3 years
ATTENDANCE
AT
COUNCIL OF
GOVERNORS
MEETINGS
1 from 2
2 from 3
2 from 2
Dec 2011
Dec 2011
Dec 2012
3 years
3 Years
3 Years
4 from 5
2 from 2
2 from 2
The Trust held elections in the staff constituency in November 2012. Dr Tarun Solanki and
Angus Maccormick were newly elected and Dr Andy Tandy’s term of office ended on the 31
November 2012.
5
Trish Hilton was appointed originally in December 2011 to complete the term of office of a
staff governor who resigned ahead of their normal expiry date in July 2011. This was a one
54
year appointment to 30 November 2012. Trish Hilton was re-elected in November 2012 for a
further three year term.
Partnership Governors to 31 March 2013
STAKEHOLDER
ORGANISATION
NAME
DATE
APPOINTED/REAPPOINTED
TERM OF
OFFICE
Dec 2009
3 Years
ATTENDANCE
AT MEMBERS’
COUNCIL
MEETINGS
0 out of 3
Jan Hull7
NHS Somerset
Ian Lewin6
Somerset Clinical
Commissioning
Group
Universities of
Plymouth and
Bournemouth
Universities of
Plymouth and
Bournemouth
West Somerset &
Sedgemoor District
Council
March 2013
3 years
1 out of 1
Dec 2009
3 Years
3 out of 5
March 2013
3 Years
0 from 0
Dec 2009
3 years
2 out of 5
West Somerset &
Sedgemoor District
Council
South Somerset &
Mendip District
Council
Somerset
Partnership NHS
Foundation Trust
Somerset
Partnership NHS
Foundation Trust
Taunton Deane
Borough Council
Somerset County
Council
Dec 2012
3 years
2 from 2
Dec 2011
3 Years
2 out of 5
Dec 2009
3 Years
1 out of 3
Dec 2012
3 years
0 from 1
Aug 2011
3 Years
5 out of 5
Dec 2009
3 Years
3 out of 5
9
Susan Twose
Dr Ann Humphreys
Duncan McGinty11
Doug Ross
10
Sue Steele
Diana Rowe13
Sue Balcombe
12
James Hunt
Stephen MartinScott
8
From the 1st April 2013 all Primary Care Trusts in England are to be abolished and
commissioning of local health services will become the responsibility of the new Clinical
Commissioning Groups.
6
Ian Lewin, has been appointed Partnership Governor for the Somerset Clinical
Commissioning Group, and is a replacement for
7
Jan Hull who resigned as the Partnership Governor (representing NHS Somerset) in April
2012, to take up a new role as Managing Director designate of the Commissioning Support
Group.
8
Dr Ann Humphreys, Partnership Governor for the Universities of Plymouth and Bournemouth,
was appointed as a replacement for
9
Susan Twose in March 2013.
55
10
Doug Ross, Partnership Governor for West Somerset & Sedgemoor District Council was
appointed as a replacement for Councilor
11
Duncan McGinty in December 2012
12
Sue Balcombe, Partnership Governor for Somerset Partnership, was appointed as a
replacement for
13
Diana Rowe in December 2012.
56
6.
6.1
SUSTAINABILITY
Introduction
This report outlines the actions taken during 2012/13 in developing the Trust’s Sustainability Strategy
by reviewing the components of the Good Corporate Citizen Model. The report highlights in particular,
that a significant amount of activity has been spent on developing the strategic public/private sector
partnership with Schneider Electric in respect of the management of energy which guarantees to
reduce energy consumption on the Musgrove Park Hospital site by 40% with a resultant reduction in
carbon emissions of 43%. This is far in excess of the targets of 10% by 2015 and 34% by 2020, which
have been set for the NHS nationally. Current data indicates the Trust has now achieved the 2015
target with an 11% reduction in carbon from the inception of the project refer to table 1 in the main
body of the report.
A subsequent initiative supported by Schneider Electric has been the launch of an environmental
campaign ‘A Greener Musgrove Park’.
6.2
Background
The Trust implemented its Sustainability Strategy in June 2009. It was developed in response to the
Department of Health’s recommendation to utilise the Good Corporate Citizenship self-assessment
model updated in 2012 and to adopt the publication ‘Saving Carbon, Improving Health’.
Amongst the information contained within the Sustainability Strategy are action plans created from
responses to the questions forming the Good Corporate Citizen self-assessment model. The model
comprises six sections covering:






6.3
Transport
Facilities Management
Procurement and Food
Employment and Skills
Community Engagement
New Buildings
Good Corporate Citizen Progress
The new version of the good corporate citizen self-assessment is currently being populated; this will
help to determine next actions to be taken. Meanwhile the following activity has either been achieved
or is in progress:
6.3.1
Transport

Implementation of an employee cycle scheme: to encourage staff to cycle to work with
all staff members able to purchase a bicycle via a salary sacrifice scheme. This means
staff can save up to 48% on the cost of a new cycle. The Trust reduces the amount it
spends on employee National Insurance contributions, 88 staff have taken up the
scheme during 2012/13 and savings to Trust are £13,600.
57
6.3.2

Implementation of a Trust lease car scheme: to promote the purchase by staff of new
lower carbon emission vehicles, the Trust introduced this scheme in July 2012 via a
salary sacrifice arrangement. To date 85 staff have taken up the scheme with a
resultant estimated 30% reduction in carbon emissions from cars used on business
matters.

The current Travel Plan for the Trust is under review considering public transportation,
cycling schemes, promotion of greener cars and wider use of telephone conferencing
for meetings.
Facilities Management
'Estates Refurbishment and Carbon/Energy Reduction Programme’
The project is well underway and schemes to upgrade inefficient plant, steam distribution and
lighting is now largely complete. The benefits of the project are beginning to be realised, with
an ‘in year’ 1.7% reduction in gas and 8.5% reduction in electricity. A significant number of
hot water leaks have been repaired which has not only reduced water usage but also gas
consumption. Water usage is down by c. 10% in year.
A Combined Heat and Power (CHP) plant and associated waste heat boiler has recently been
commissioned and is operating generating approximately 33% of the Hospital’s electricity
requirement whilst recovering the resultant heat from the generator into the main steam boiler
plant.
A further innovation is the installation of photo-voltaic panels on Duchess Building which feeds
carbon neutral power into hospital’s electricity supply.
Other initiatives completed within the project include insulation improvements, improved
steam distribution heat recovery, provision of variable speed drives on all electric motors,
improved lighting and the replacement of old hot water storage vessels with instantaneous
plate heat exchangers.
Carbon Trends
The following tables show the consumptions and predicted carbon savings during 2012/13.
Table 1
58
Waste
Two new compactors on-site support improved waste recycling including cardboard.
Recycling of a range of dry mixed waste has been improved and the number of waste
collections from the Trust has been reduced. The overall amount of waste recycled has
increased to an average of 83% of total waste refer Table 2. Due to improved segregation
clinical waste weights have also reduced by 6% in the year.
The Dip in recycling noted in June was due to a temporary system failure.
Table 2
Recycling %
100%
90%
80%
70%
60%
50%
40%
30%
84%
91%
86%
85%
83%
77%
91%
90%
84%83%
82%
45%
Recycling % 2012/2013
Target %
Recycling % 2011‐2012
Other FM Related Issues
In conjunction with the energy project a campaign was launched before Christmas 2012 to
highlight and educate staff to act in a sustainable way. Over 100 environmental champions
have been recruited and are currently being trained to provide ideas and feedback on
sustainable issues. The initial focus of the campaign is to promote awareness of energy usage
and wastage throughout the Trust. The culmination of phase one of the campaign is a ‘green
trees red stop sign’ sticker promotion launched on NHS sustainability Day on 28th March 2013.
The visual aids are to empower all staff within the Trust to switch off equipment, lights etc.
with a green Tree sticker. Energy usage within different buildings within the Trust is available
on the environmental website on the intranet.
Phase two of the environmental campaign will be focusing on waste and recycling.
An environmental impact assessment tool (SPROUT) is now available as an option for
inclusion in business cases. This enables the financial and sustainable impact of projects to
be determined (in terms of energy and consumable costs, for example).
6.3.3
Procurement and Food
Electric hand driers have been installed in public and staff toilets throughout the hospital, and
will be rolled out to theatres shortly delivering an estimated annual saving of paper towels of
£45,732.
59
The procurement of consumables for use within the hospital is currently under review with the
aim of providing a central store and reducing deliveries.
Local fruit and vegetables supplies are being used for Patient, Staff and Visitor menus.
The furniture recycling scheme is still in operation and has generated savings of £5,366 to the
period to 31st March 2013.
6.3.4
Employment and Skills
All job descriptions now include a ‘sustainability’ clause requiring staff to be aware of their
usage of products and resources.
An environmental attitude and awareness survey was undertaken as part of the Energy
Campaign during December 2012, the summary and conclusions are as follows:





6.3.5
370 members of staff responded to the survey a response rate of 9%, just below
average for NHS environmental survey;
Levels of motivation (above average) but awareness levels were lower than average;
Staff felt recycling at the Trust could be improved as they were unaware of the extent to
which waste and recycling are undertaken at the Trust, it was felt that better
communications would improve this engagement and awareness;
Issues relating to heating (specifically overheating in some areas) provoked some
frustration amongst staff as they felt nothing was being done to rectify the position;
71 environmental champions were recruited through the survey representing 19% of
respondents and 2% of Trust Staff.
Community Engagement
As part of the Greener Musgrove Park campaign Taunton and Somerset NHS Foundation
Trust participated in climate week beginning 10th March 2013, various displays and
presentations took place in various locations throughout the hospital. The displays included
local organisations including Taunton Transition, local food retailers as well as Wessex Water
and Energy Saving Trust.
Publicity has been generated for the new ‘Musgrove Gallery’ and individual ‘Art for Life’ (A4L)
projects
On 28th March 2013 the Trust joined with over 100 health providers in promoting NHS
Sustainability Day of Action.
6.3.6
New Buildings
The major significant new build undertaken during 2012/13 is the construction of the hospital’s
new Jubilee Building. The works are progressing well and the project team is working in
partnership with our main building contractor, BAM are voluntarily assigned to the Considerate
Constructors Scheme. This is the national initiative set up by the construction industry to
improve its image.
Construction sites and companies that register with the Scheme are monitored against a Code
of Considerate Practice, designed to encourage best practice beyond statutory requirements.
The Scheme is concerned about any area of construction activity that may have a direct or
indirect impact on the image of the industry as a whole. The main areas of concern fall into
three categories: the general public, the workforce and the environment.
60
Following a recent inspection of the construction site BAM received outstanding results for the
following areas:








6.4
Considerate – communication and co-ordination between contractor and their
employees, Trust Staff
Environment – recycling, waste, energy efficiency and sustainable issues including
travel plans for employees
Appearance – ensuring work areas especially those visible to the public project a
positive image
Good neighbour- wider communication to ensure advance notification of progress
with project including the Trusts neighbor’s
Respectful – to ensure all staff adhere to BAMs dress code and rules and provision of
site welfare facilities
Safety - The Construction Phase Health & Safety Plan is reviewed and updated
regularly as the works progress
Responsible – on site first aid, emergency and evacuation procedures and protocols
development
Accountable - a comprehensive and challenging CCS Action Plan, encompassing a
number of key objectives, was drawn up at the start of the project and performance is
reviewed and updated regularly
Monitoring and Performance
Table 3 below provides 4 years data, with the columns on the right showing the %change.
Table 3
2009 / 10
2010 / 11
2011/12
2012/13
%
Difference
11/12 –
12/13
Cumulative
%
difference
from
2009/10 to
date
Gas - kWh
25,648,671
26,282,844
23,267,365
22,894,225
-1.6
-11
Electricity
- kWh
Water
–
m3
9,487,604
9,741,089
9,438,969.2
8,638,973
-8.5
-9
128,920
134,146
141,011
127,489
-9.6
-1.1
Clinical
Waste
tonnes
Household
Waste
tonnes
%
Average
Recycle
406
416
388
366.4
-5.6
-10
565
578
568
575
+1.2
+1.8
Not Known
60% (Feb
77%
82%
+5
+22
11)
61
For the first time in 2012 / 13 paper usage is monitored refer to Table 4.
Table 4
6.5
DESCRIPTION
2011/12
QUANTITY
2012/13 QUANTITY
Copier paper 80gsm
19,741 Reams
10,090 Reams
Trust Letterhead
Appointments Booking
Letterhead
2,371 packs
2,839 packs
310 packs
369 packs
Letterhead NHS Logo only
92 packs
83 packs
% Difference
-49
+20
+19
-10
Annual Targets for 2011/2012
From the previous annual report vast improvements have been achieved in all of the target
areas, refer table 5 below. It is recognised that the targets set are very ambitious; however
this ambition is driving continual improvement.
Table 5
Target
 15% reduction in clinical
waste weights
Key Actions to Achieve
Further enhance waste audits
Undertake internal audit of waste
process
 Maintain levels of waste
being recycled
Improve segregation at ward level
 20% reduction in paper
being used
.
Critically appraise paper usage
ongoing
Where possible create data to
understand volumes used ongoing
Increase use of technology to
promote paperless meetings (I
pads etc.)
Consider opportunities to
communicate electronically with
patients ongoing
Complete measures detailed within
the Energy Project
40% energy reduction from
2010 position
% Change
6% reduction in clinical
waste achieved
Internal audit of waste
process completed
Increase of 5% achieved
49% reduction in copier
paper. Other areas of
paper usage have seen
an increase refer table 4
10.2% reduction
achieved
Annual Targets for 2013/2014
We continue to pursue ambitious targets; the following targets for the Trust have been set for 2013/14:
62
Table 6
Target
Key actions to Achieve
15% reduction in clinical waste weights
Continue to develop an improved internal waste
audits.
Link target to the ‘Greener Musgrove Park’ campaign
Ensure clear feedback and support is provided to
those areas responsible for poor segregation.
Maintain levels of waste being recycled
those areas responsible for poor segregation
Reduce food waste
those areas over ordering
Undertake regular auditing to reduce to below
national average (currently 6%)
Food procurement
Work with NHS Supply Chain to retender the main
cook freeze food supply contract.
Develop seasonal menus
Seek opportunities to source local food where
possible
40% energy reduction from 2010 position
Complete measures detailed within the Energy
Project and energy awareness campaign
63
7.
REGULATORY RATINGS
Once authorised, each NHS Foundation Trust (‘FT’) is subject to its Terms of Authorisation (‘Terms’),
a detailed set of requirements which must be met by the FT. Monitor assesses a trust’s compliance
with its Terms and the extent to which there is a risk of breach of them by reference to its Compliance
Framework. The Compliance Framework, which is typically updated annually by Monitor, sets out the
detailed rules, regulations and guidance to be followed and applied by the FT. It also explains how
Monitor will intervene if an FT breaches, or is at risk of breaching its Terms.
Each year, all NHS FTs are required to submit their Annual Plans (essentially, a rolling three year
plan) to Monitor. Once Monitor has analysed the Annual Plan, it assigns two risk ratings to each trust.
The risk ratings denote Monitor’s view of the extent to which an FT is at risk of breaching its Terms.
The two categories of risk for which a rating is given are:
 Governance: for which the rating signifies whether the FT is being sufficiently well managed to
deliver high quality services, is meeting national targets and core standards set by the
Government, and is delivering all of the services it has a legal obligation to provide (under
contract with its commissioners); and
 Finance: for which the rating signifies whether Monitor has any concerns about the financial
performance of the Trust.
Monitor additionally requires all FTs to report quarterly and to self-certify the extent to which the
requirements of the Compliance Framework have been met. The two risk ratings are then up-dated by
Monitor following submission and its review of each quarterly report.
The financial risk rating is numerically described on a scale of 1 – 5, where 1 is high risk and 5 is low
risk. A colour-coded risk rating is used for governance, on a scale which moves from green, ambergreen, amber-red, to red, where green is low risk and red is high risk.
Where trusts are assigned a governance risk rating of green, there are no further reporting
requirements. The level of further reporting required increases in intensity as the governance risk
rating moves along the scale. Trusts’ with a governance risk rating of red will be required to meet with
Monitor to identify whether further intervention is necessary. Similarly, in respect of the financial risk
rating, trusts with a rating of 4 or higher will have no further reporting requirements. Trusts with a
Financial Risk Rating of lower than 3, will be required to provide additional information, including a
recovery plan. The extent to which trusts’ with a financial risk rating of 3 will be required to provide
additional information to Monitor, will depend on the circumstances (for example, taking into account
any liquidity concerns or when the achievement of a financial risk rating of 3 is lower than was
planned).
The financial plan has delivered a Financial Risk rating of 3 under the current regime and a 4 under
the proposed Continuity of Service measure that has been subject to a recent consultation process.
The Trust’s governance risk rating has been a consistent green during 2012/13 and this is expected to
continue during 2013/14.
64
Table of analysis
Previous Year
2012/13
Financial risk
rating
Governance risk
rating
Annual Plan
2012/13
Q1
2012/13
Q2
2012/13
Q3
2012/13
Q4 2012/13
3
Green
3
Green
3
Green
3
Green
4
Green
Previous Year
2011/12
Financial risk
rating
Governance risk
rating
Annual Plan
2011/12
Q1
2011/12
Q2
2011/12
Q3
2011/12
Q4 2011/12
3
Amber-Red
3
Green
3
Amber-Red
3
AmberGreen
3
AmberGreen
65
8.
STATEMENT OF THE ACCOUNTING OFFICER
Statement of the chief executive’s responsibilities as the accounting officer of Taunton and
Somerset NHS Foundation Trust
The NHS Act 2006 states that the chief executive is the accounting officer of the NHS foundation trust.
The relevant responsibilities of 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 the Taunton and Somerset 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 Taunton and Somerset NHS foundation trust and of its’ income and expenditure,
total recognised gains and losses and cash flows for the financial year.
In preparing the accounts, the Accounting Officer is required to comply with the requirements of the
NHS Foundation Trust Annual Reporting Manual and in particular to:




Observe the Accounts Direction issued by Monitor, including the relevant accounting and
disclosure requirements, and apply suitable accounting policies on a consistent basis;
Make judgements and estimates on a reasonable basis;
State whether applicable accounting standards as set out in the NHS foundation trust Annual
Reporting Manual have been followed, and disclose and explain any material departures in the
financial statements; and
Prepare the financial statements on a going concern basis.
The accounting officer is responsible for keeping proper accounting records which disclose with
reasonable accuracy at any time the financial position of the NHS foundation trust and to enable him/her
to ensure that the accounts comply with requirements outlined in the above mentioned Act. The
accounting officer is also responsible for safeguarding the assets of the NHS foundation trust and hence
for taking reasonable steps for the prevention and detection of fraud and other irregularities.
To the best of my knowledge and belief, I have properly discharged the responsibilities set out in
Monitor’s NHS Foundation Trust Accounting Officer Memorandum.
Signed …………………………………….
Chief Executive
Date: 29 May 2013
66
9.
ANNUAL GOVERNANCE STATEMENT
Scope of responsibility
As Accounting Officer, I have responsibility for maintaining a sound system of internal control that
supports the achievement of the Taunton and Somerset NHS Foundation Trust’s (‘the Trust’) 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 Trust is administered prudently and economically and that resources are applied
efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation
Trust Accounting Officer Memorandum.
The purpose of the system of internal control
The system of internal control is designed to manage risk to a reasonable level rather than to
eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide
reasonable and not absolute assurance of effectiveness. The system of internal control is based on an
ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims
and objectives of the Trust, to evaluate the likelihood of those risks being realised and the impact
should they be realised, and to manage them efficiently, effectively and economically. The system of
internal control has been in place in the Trust for the year ended 31 March 2013 and up to the date of
approval of the annual report and accounts.
Capacity to handle risk
The Trust has identified an executive director with responsibility for progressing risk management in
the organisation. The Director of Operations has clearly defined risk management responsibilities and
is supported by an Operational Lead for Governance along with specific governance facilitator
resource. Responsibilities for risk management are clearly defined within job descriptions for all of
these roles.
The Trust’s Governance Support Unit is responsible for providing appropriate training, support and
guidance to enable all managers to carry out their risk management responsibilities. Specific training
courses on risk management for managers, risk assessment, incident management and investigation
are supported by a corporate induction and mandatory update programme covering all regulatory
requirements.
The Director of Operations and Operational Lead for Governance are key members of the Trust’s
Operational Board, where the risk register is reviewed monthly to ensure operational risks are being
adequately controlled.
The Operational Lead for Governance is a member of the Trust’s key operational management group
for governance, the Quality Assurance Committee (QAC). The QAC meets monthly to monitor
progress with corporate and operational plans and receive assurance reports on all regulatory
requirements in accordance with its reporting schedule.
The Operational Lead for Governance is also a member of the Trust’s Learning for Improvement
Group. This group meets regularly to share issues raised following incidents, complaints, concerns
and claims, along with information from other key sources, such as morbidity and mortality reviews.
This enables sharing of good practice and lessons learned via directorate governance structures and
allows for direct input into the Trust’s improvement programme.
67
The risk and control framework
The Trust’s Governance Policy details how risk will be identified, evaluated and managed. It gives
details of the monitoring arrangements and the authority for decision-making through identified posts
or committees. The main methods for the identification of risk are:
•
Review of compliance with key standards, for example the CQC Registration Requirements and
the NHS Litigation Authority Risk Management Standards, and legislation such as the Health
and Safety at Work Act (1974).
•
Executive review of annual and strategic objectives to identify potential risks to meeting those
objectives.
•
Local risk assessment at departmental level, feeding up to divisional risk registers.
•
Facilitated risk identification sessions at various levels in the organisation.
•
Incident reporting and complaints information.
•
Information from external sources such as audits and patient and staff surveys.
All risks are assessed and evaluated using a standard form and scoring system, allowing direct
comparison of all risks. From this evaluation, risks are categorised into one of three accountability
levels, and responsibility for the control and monitoring of the risk is allocated to the department, the
directorate or the Trust executive team, depending on the level identified. Responsibility for completing
actions is allocated to an individual manager, with monitoring carried out by the relevant directorate
committee or Trust Executive Director. The three accountability levels are set based on the Trust’s risk
appetite, which is regularly reviewed by the Board.
Risk identification is linked to the setting of organisational objectives, as detailed in the Assurance
Framework. Capital planning includes an assessment of risk issues, and spending is prioritised on a
risk basis. All papers considered by the Board are referenced to the risks they are aimed at
addressing. The Assurance Framework includes details of the significant risks that may affect the
Trust achieving its objectives, how they are currently controlled and what sources of assurance the
Board have that the risks are being managed appropriately. It also details action that is necessary to
reduce the risks or improve sources of Board assurance, with prioritisation based on the standard
Trust risk evaluation process. The Assurance Framework includes a summary of current performance
against key indicators identified within the strategic objectives and is used in setting the Board agenda
for each meeting. This is supported by regular clinical quality reports which include key measures
along with learning from incidents, complaints, concerns and claims.
Information and data security risks are identified and managed through the Trust’s risk assessment
and incident reporting processes. The Trust has established an Information Governance Steering
Group to monitor this process and provide assurance on the systems in place for managing
information risks.
As part of its ongoing commitment to risk management, the Governance Support Unit develops an
annual plan, monitored by the Governance Committee that includes key risk management objectives.
The Audit Committee workplan is linked to risk and ensures the committee, which receives reports
from senior managers and internal or external audit as appropriate, tests the controls in place for
managing the key risks.
Assurance on compliance with CQC registration requirements, along with NHSLA Risk Management
Standards compliance and other key regulatory requirements, is provided to the Trust Board’s
Governance Committee via the work of the QAC. The QAC reviews the assurances in place for all
requirements in line with an annual plan, providing regular updates to the Governance Committee. In
68
addition, the Governance Committee carries out a full annual review of compliance with CQC
registration requirements.
The Trust involves its key stakeholders in managing risks which impact on them in a variety of ways.
The Members’ Council of Governors has a key role in supporting and challenging the Board and, in
addition to the main council, the Trust has developed three working groups dealing with patient care,
strategy and communications and engagement with recruitment of members. Each of these groups of
governors, through their work, influence how risks are managed. In addition, the Trust has a strategy
and action plan for patient and public involvement which is monitored by the Patient Experience
Committee. Lay users sit on a wide variety of Trust committees and groups that address risk issues,
including the QAC.
The Trust’s key risks for 2013/14 are:

Meeting the highest quality standards: The Trust continuously strives to deliver the highest
standards of care to patients. This is measured through a range of indicators at individual ward
level, such as the number of patients affected by an infection or pressure damage. One of the
critical issues for achieving the highest quality of care is that patients are nursed in the
appropriate ward. There can be pressure on maintaining this standard at times of high levels of
emergency admissions into the hospital. This places pressure both on bed capacity and
ensuring the correct levels of staffing are available at all times. These risks will be actively
managed throughout the year to ensure that the fundamental standards that patients expect are
delivered at all times.

Performance Targets: The NHS Constitution confirms rights for every patient to be seen within
18 weeks from referral to treatment time (RTT). Failure to comply with the Constitution presents
financial, reputational and quality risks. During 2012/13, there have been pressures in particular
specialties to maintain this standard, particularly in orthopaedics where demand for more
specialist work has increased overtime. Additional consultant capacity has been created within
the team. However, there remains a risk that these standards might not be maintained
throughout the whole year if demand outstrips the level of capacity available. Specific action
plans are in place within every specialty and performance is tightly monitored.

Financial Plan: As the financial pressures on the NHS increase, the challenge for the Trust also
increases. In 2013/14 the Trust is required to make a cost improvement savings of £11.8m.
Achieving this whilst still maintaining and improving quality of care will present particular risks to
the organisation. A range of savings plans have been agreed at local and corporate level with
clear processes in place to monitor these and to ensure that no reductions in cost impact on
quality of care.
In the longer-term there are a number of key strategic risks faced by Taunton and Somerset NHS
Foundation Trust relating to the need to provide the highest standards in specialist services. The Trust
will continue to look at how these risks can be mitigated by working more closely with other
organisations, both within Somerset and in neighbouring counties.
The demographic changes in the population also represent a future risk to all acute hospitals in
delivering more care, but with less money. The Trust is fully supportive of the Somerset Clinical
Commissioning Group’s ambition to provide more care closer to patient’s homes and will actively seek
to provide services on an ambulatory basis away from the Musgrove Park Hospital site to reduce the
pressure on acute hospital services, whilst drawing on the skills and expertise of existing clinical
teams.
The Trust is fully compliant with the requirements of registration with the Care Quality Commission.
69
As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are
in place to ensure all employer obligations contained within the Scheme regulations are complied with.
This includes ensuring that deductions from salary, employer’s contributions and payments into the
Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are
accurately updated in accordance with the timescales detailed in the Regulations.
Control measures are in place to ensure that all the organisation’s obligations under equality, diversity
and human rights legislation are complied with.
The Foundation Trust has undertaken risk assessments, and Carbon Reduction Delivery Plans are in
place in accordance with emergency preparedness and civil contingency requirements, as based on
UKCIP 2009 weather projects, to ensure that the Trust’s obligations under the Climate Change Act
and the Adaptation Reporting requirements are complied with.
Review of economy, efficiency and effectiveness of the use of resources
The 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
continuous service and cost improvement.
The Trust benchmarks efficiency in a variety of ways, including the National Reference Costs Index
and by comparison with the annual surpluses generated by all foundation trusts.
Annual Quality Report
The directors are required under the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual
Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual
Reporting Manual.
The Director of Nursing and Governance leads the development of the annual Quality Account. Key
stakeholders have been involved in the development of the report. The development of the priorities
and indicators was based on all types of patient feedback over the year. A long list was approved by
the chairman of the Governance Committee and these became the substance of an online survey
inviting responses from the public, hospital staff, LINKs, governors and members, and other
organisations with whom the Trust works. Over 140 responses were received and the results were
presented to the Council of Governors’ Patient Care Group. Priorities identified were very similar from
each group of respondents and these were considered by the Governance Committee. This
committee, and subsequently the Board, accepted the recommendations based on the results of the
survey.
The Associate Director of Nursing, Corporate and Clinical Support Division, supported by clinical
information analysts, clinical audit facilitators and other specialists, have coordinated the preparation
of the Quality Account. Controls are in place to ensure that all the Trust's employees have the
appropriate skills and expertise to perform their duties. This includes the provision of relevant training
and helps to ensure the accuracy and reliability of data collected and prepared by employees and
which is used to assess the quality of the Trust's performance.
The quality metrics included in the report have been regularly reported through Trust governance
structures, including the Governance Committee and Trust Board where appropriate.
70
Data quality issues are addressed through the Trust’s information governance systems in line with its
Information and Data Quality Policy.
The metrics include key measures developed with the Trust’s principal commissioners, NHS
Somerset, to provide them with assurance that the Trust is providing high quality care. Additional
measures relating to patient experience are provided by the monthly assessments that the Trust has
established, overseen by the Trust’s Patient Experience Committee.
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 included in this annual report and other
performance information available to me. My review is also informed by comments made by the
external auditor in its management letter and other reports. I have been advised on the implications of
the result of my review of the effectiveness of the system of internal control by the Board, the Audit
committee and Governance committee, and a plan to address weaknesses and ensure continuous
improvement of the system is in place.
The Board Assurance Framework provides me with evidence that the effectiveness of controls that
manage the risks to the organisation achieving its principle objectives have been reviewed. The most
significant assurance on risk management that informs my review is the achievement of Level 3 of the
NHSLA Risk Management Standards in December 2012. My review is also informed by:

The Trust’s assurance process for monitoring levels of compliance with Care Quality
Commission Essential standards of quality and safety, including review of feedback from CQC
inspections;

Programme of work undertaken by Internal Audit;

Clinical Audit annual programme, including relevant national audits;
•
Deanery and college inspections;
•
NPSA National reporting and Learning System Incident Report.
In assessing and managing risk, the Board and its sub-committees have a substantial role to play in
reviewing the effectiveness of the system of internal control as follows:
Trust Board: Through the review and approval of the Trust risk register, Board Assurance Framework
and key performance indicators
Audit Committee: Through the review of the internal audit programme of work, receipt of reports from
external audit, and assurances gained through management reviews requested by the Audit
Committee.
Governance Committee: Through the review of Care Quality Commission registration process,
confirming the process by which the standards have been assessed, through the review and
management of the Trust’s risk register and Board Assurance Framework and the development of the
Trust’s Governance Policy. The internal audit programme for 2012/13 identified internal control
weaknesses in relation to the arrangements for clinical, domestic and confidential waste management,
data quality - maternity department and the accommodation letting process (advisory). Action plans
71
were developed to resolve the issues identified, and these were monitored by the Trust’s Audit
Committee.
Conclusion
No significant control issues have been identified.
Signed……………………….…..
Date: 29 May 2013
Chief Executive
72
10.
QUALITY ACCOUNTS REPORT
Taunton & Somerset NHS Foundation Trust Quality Report 2012/13 Incorporating the Quality Account 31 March 2013 Taunton and Somerset NHS Foundation Trust - Annual Report and Accounts 2012/13
73
74
Patient Safety
Patient Experience
Making the most of Musgrove
TAUNTON AND SOMERSET NHS FOUNDATION TRUST
Quality Report 2012/13
Incorporating the Quality Account
Part one
Foreword - From the Chief Executive
As Chief Executive, I am passionate about the quality of the service we provide to our patients at
Musgrove. Quality drives our strategic ambitions and guides the hospital to make the right
decisions about the services we provide so we can continue to deliver the very best levels of care
to the community we serve. Quality is central to everything we do and is an integral part of the
three principles that staff adhere to here at Musgrove:
Patient Safety - to keep our patients safe from avoidable harm.
Patient Experience - to give our patients the best experience possible while they are in our care
so that at least 95% of patients rate the care we provide as ‘excellent’.
Making the Most of Musgrove - to run the hospital as efficiently as possible, at a cost of 10%
less than the average hospital in England, by making sure every penny we spend delivers the
best levels of care and clinical outcomes for all patients.
These have been our guiding principles at Musgrove for a number of years, and they will continue
to be, because they encapsulate the three areas we know we need to focus on if we are to deliver
quality care to our patients. Staff at Musgrove live and breathe these principles and use them to
shape and make improvements to the services they provide; from staff working on the wards, in
clinics and in theatres, to staff working in our support services and management teams.
Our focus on quality has resulted in us achieving some excellent results this year. Our Intensive
Therapy Unit (ITU) has been singled out as achieving the lowest mortality (death) rates in the
country, when compared to ITUs of a similar size, meaning it is one of the safest ITUs in England.
Our infection control rates are also exemplary and are a testament to the hard work of our staff
who continuously strive to keep our patients safe from harm.
We have a lot to be proud of here at Musgrove. However, you will see by reading this year’s
quality accounts there are areas where we have not met the quality targets we set for ourselves,
for example, ensuring every patient that needed help with eating received it and halving our rate
of avoidable hospital acquired grade two pressure ulcers.
There is no room for complacency in these areas and it is vital that during 2013 we continue to
make improvements. As the findings of the Francis Report show, complacency and a lack of
reality about the quality of the service that health organisations provide ends with disastrous
consequences. I have been deeply distressed by the contents of this report and my thoughts
75
Patient Safety
Patient Experience
remain with the individuals and their families and carers who have been affected by the poor
quality of care delivered at Mid Staffordshire.
Although I recognise that staff working at Musgrove are extremely dedicated to their patients as
well as their patients’ families and carers, I also know that we do not get it right for every patient,
every time and it is crucial that as an organisation we, like all of the NHS, acknowledge that no
hospital or care setting is immune to failures.
To ensure we learn from and act upon the Francis Report a team of staff from across the hospital;
including healthcare assistants, nurses, doctors and board members are looking closely at the
findings and recommendations to see where changes and/or improvements need to be made at
Musgrove. This team will also be looking at how we listen to our staff, to ensure they feel
comfortable and supported to raise any concerns they have at the earliest opportunity; particularly
about the quality of care being provided.
I know that being passionate about the quality of care we provide only results in excellent
performance when we listen to, and act upon, feedback from our staff. In June 2012, over 340
members of staff from across the hospital attended a number of ‘Big Conversations’. The Big
Conversations marked the beginning of a fundamental shift in the way we lead and work at
Musgrove using the excellent and established techniques of our Improvement Network to put our
staff - the people who know the most - at the centre of change.
Based on what staff said at these events we identified 12 ‘quick wins’ that if implemented would
make an immediate difference to both patients and staff. I am pleased to say these ‘quick wins’
were completed by September.
In September, we went on to launch six enabling projects, which were set up to look at solving
some of the more complicated issues that affect staff across the hospital, and the ‘first 10 teams’
who have been working in their own areas to improve patient care and staff satisfaction.
Since September, more and more teams have been inspired to use this way of working and many
have held their own ‘mini conversations’ which they have used to identify what’s getting in the way
of providing the very best levels of care to patients and their families in their areas. The feedback
we have had from staff about this way of working is that they feel valued and listened to and
empowered to get on and make improvements for the benefit of patients, their families and our
staff; all with the knowledge that they have the full backing of our Improvement Network and the
Board.
To the best of my knowledge, the information contained in the quality report is accurate and I
hope you find our quality accounts informative and useful. I would like to hear your opinions on
how we run our services and any improvements you think we could make.
Signed………………………………………………………………
Jo Cubbon
Chief Executive
76
Patient Safety
Patient Experience
About Us
Musgrove Park Hospital is part of Taunton and Somerset NHS Foundation Trust.
We are the largest General Hospital in Somerset and serve a population of over 340,000. Each
year 40,000 patients are admitted as emergencies; 10,000 patients are admitted for elective
surgery; 26,000 are seen for day case surgery; 232,000 patients attend outpatient appointments;
48,000 attend accident and emergency and over 3,000 babies are born in the maternity
department. In addition 170,000 diagnostics tests are carried out and almost 1,000 patients are
admitted to critical care each year.
We have an annual budget of nearly £240m. The hospital has over 700 beds, 30 wards, 15
operating theatres, an intensive care and high dependency unit, a medical admissions unit and a
fully equipped diagnostic imaging department. Our purpose built cancer treatment centre includes
outpatient, chemotherapy day care, and radiotherapy and inpatient facilities. Musgrove Park also
has a specialised children’s department including a paediatric high dependency bay and provides
Neonatal Intensive Care for all of Somerset. The Trust employs over 4000 staff.
Musgrove Park has three clear principles: Patient Safety, Patient Experience and Making the
Most of Musgrove. We are committed to delivering the safest possible patient care; the best
possible experience for patients and making the very best use of the resources we have.
Some of our achievements in 2012/13
Environment & Services
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We were given Trauma Unit designation as part of the new specialist trauma network in the
NHS South region. We are therefore designated to provide emergency care to patients with
life threatening injuries.
Our Beacon Centre (Cancer Centre) won the CHKS’ International Quality Improvement
Award.
We were given a gold star for our state-of-the-art operating theatres. The National Audit of
Laparoscopic Theatre Equipment 2012 awarded us the highest grade for our integrated
theatres, which meet the most stringent standards of safety and design.
We installed a new £1.5 million CT scanner at Musgrove. This scanner is the first of its kind in
the West of England and can provide a head-to-toe scan in about ten seconds, without the
patient having to be moved.
The Jubilee Building was ‘topped out’ in style to mark the completion of the building’s highest
point.
We were awarded £600k by the Department of Health to enable us to make improvements to
our maternity unit.
Patient Experience

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We were one of only three hospitals in the South West to score five out of five for patients’
privacy and dignity, the hospital environment and its food.
We were recognised as an Outstanding Hospital by the Care Quality Commission (CQC).
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Safety
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We were shortlisted for a national Patient Safety Award. Musgrove was nominated in the
‘Changing Culture’ category, reflecting the hospital’s work in putting patients at the heart of
everything it does.
The proportion of patients surviving infection (sepsis) rose, despite increasing numbers of
patients being diagnosed with the condition. The ‘surviving sepsis’ team were shortlisted for a
Health Service Journal (HSJ) Award in patient safety for their excellent achievements in this
area.
National statistics showed that our cardiology team was one of the quickest in the country for
the speed with which a patient undergoes emergency heart surgery following a heart attack.
Dementia
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Staff from Wordsworth Ward transformed part of the ward to create a tranquil environment for
their elderly patients.
Following the success of the dementia-friendly environment created in Sedgemoor Ward, we
bid for and were awarded £150k from the National Dementia Challenge Fund which will
enable us to similarly improve the environment on an orthopaedic ward during 2013.
We set up a completely new process for screening older patients with memory problems to
assess their risks of dementia and enable onward referral to specialist services which,
through the dedication of team seconded from other roles, has achieved remarkable results.
Our staff
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The dedication and hard work of our staff were recognised at our very own MAFTAs
ceremony (Musgrove Awards for Tremendous Achievement).
A new team of Governors were welcomed to Musgrove following an election campaign.
Representatives for the Taunton Area, West and East Somerset and the area outside the
county were selected, alongside Staff Governors.
We celebrated 5 years of being an NHS Foundation Trust.
Our epilepsy nurse specialist, Teresa Smith, was shortlisted from over 150 nominees for the
Claire Rayner Patient’s Choice Award.
Our Intensive Therapy Unit was recognised by a national independent survey as one of the
best in the country for its mortality (death) rates.
Putting our staff – the people who know the best - at the centre of change
In June 2012, Jo Cubbon, Chief Executive of Musgrove, hosted a number of Big Conversations
with staff from across all levels and roles in the organisation.
These conversations were set up to give staff the chance to talk openly about what gets in the
way of delivering the very best levels of care to our patients and their families. The absolute focus
of these conversations - and the actions that followed – were to support and enable staff to make
changes which would make us all feel satisfied and proud of the service we provide at Musgrove.
Over 340 members of staff from across all groups and levels attended the Big Conversations.
Based on what staff said at these events we identified a number of ‘quick wins’, ‘enabling projects’
and ‘first 10 teams’ to drive improvement and unblock the frustrations that stop staff delivering the
very best care to patients.
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Between July and September 2012, with direct involvement from staff, we identified and
completed 12 ‘quick wins’. In September, we launched six ‘enabling projects’ to look at solving
some of the more complicated issues that affect staff across the hospital as well as the ‘first 10
teams’ who have set up improvement projects in their areas.
Everyone involved in the ‘enabling projects’ and ‘first 10 teams’ are fully supported by the
Improvement Network and have the full backing of the Trust Board to get on and make changes
for the benefits of our patients, their families and our staff.
We are using this way of working to put staff - the people who know the most - at the centre of
change; with the next 20 teams ready to launch their improvement projects imminently.
In addition to the Big Conversations, the Chief Executive continues her regular breakfast
meetings with clinical managers and specialists where they are encouraged to share the issues
that concern them. The senior nursing team spends one day a week on the wards listening to
patients and supporting sisters and their teams to deliver compassionate care in line with clinical
standards. This process enables the senior nurses to take focused action with ward staff. Actions
have included a focus on rounding to ensure patients are regularly repositioned and their skin
inspected to prevent development of pressure ulcers; correct and timely responses to changes in
clinical observations; and responding with staff to concerns about patient care.
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Part Two: Priorities for improvement and statements of assurance from the
Board
Quality - The Patient at the Heart of Everything We Do
Strong leadership is essential within a successful organisation and as reflected in our strategic
objectives our Board is committed to ensuring the hospital provides safe quality care to our
patients. During 2012/13 we have continued to make considerable progress on embedding
quality at all levels of the organisation. At each Board meeting in addition to finance and
performance reports our Board receives a quality report which is produced by the Medical
Director and the Director of Governance and Nursing. This is supplemented each quarter by a
more detailed report covering a wider range of topics including patient complaints and concerns.
The Board has also listened to patient experiences from patients or carers themselves. These
quality reports provide the Board with information on performance with respect to a variety of
quality indicators and issues that are important to us and our patients.
In addition executive and non-executive Board Members take the opportunity to get out on the
“shop floor”. This can be working alongside staff or taking part in regular “walkabouts” visiting
different areas of the hospital, speaking to staff seeing the care given first hand and bringing back
issues which require action.
Through our quality framework we have established quality monitoring across the hospital
reporting to Divisional Boards through to the Governance Committee, a sub group of the Board.
This ensures we continually monitor the quality of care and during this process of on-going
assessment and review we involve our commissioners, Musgrove Partners (lay people) and of
course the Governors.
Stakeholder Involvement
We are fortunate in the Trust to have a strong history of working with our patients, volunteers and
members of the public which helps us to understand their experience of our care and what
aspects they feel we can do better. We are continuing to develop these relationships recognising
they provide us with rich information to assist us in the development of our clinical priorities. Our
Governors’ work-stream on “Patient Care” has been valuable in highlighting the views of the
membership and suggestions on the content and format of this report. In addition, the Trust’s
quality priorities and indicators have been informed by patients, carers, staff and members of the
public, through their involvement in patient feedback interviews, feedback from exit cards,
inpatient surveys and focus groups. We also use information from complaints and calls to our
Patient Advice Liaison Service. We hold quarterly quality monitoring meetings with our
Commissioners which ensures clear agreement on our priorities which are reflected in this report.
Taunton and Somerset NHS Foundation Trust has published Quality Accounts for three years
now and developed a system for establishing quality priorities. Firstly, a long list is drawn up,
informed by the Trust’s performance over the past year against its quality and safety indicators;
external priorities; and finally from horizon scanning. For example, last year the Trust drew from
its performance scorecard topics including patients’ recommending the Trust to friends, falls and
pressure ulcers; and from national priorities VTE and infections. The long list of ten topics was
discussed and consulted on with groups of external and internal stakeholders to develop a
shortlist. The process included involving members of the Governance Committee and Trust’s
Patient Care Group, the result of which became the substance of public online survey. The results
were presented to the Patient Care Group and agreed by members of the Governance
Committee. Many topics have been continued since last year and all topics will continue to be
reported on from ward to Board throughout the year.
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Quality Improvement Priorities 2012/13
In last year’s Quality Report we identified the following five priorities for 2012/13:
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Sustaining the reduction of Hospital Acquired Infections
Improving patient safety whilst in hospital by reducing falls and pressure ulcers
Ensuring patients receive adequate and nourishing food
Caring for patients with dementia
Improving how well we communicate.
The next few pages set out our performance against these priorities. The Board were keen to
ensure that our targets were challenging and stretched the organisation, which meant that not all
targets were achieved. However, in every case the experience has led us to greater
understanding and clear identification of the way forward. We have been able to identify what
measures are the most effective and have been able to refine these for the future. The Board
received regular updates on progress and they have been shared throughout the Trust.
Some of these priorities will remain priorities for 2013/14 following agreement when the Quality
Account was made available to Board members for comment in March 2013. However, all the
topics will continue to be monitored by the Trust Board and we plan to continue to report on them
in future years.
Sustaining the reduction of hospital acquired infections
Methicillin Resistant Staphylcoccus Aureus (MRSA) Blood stream Infections
Our aim was to have ideally zero but no more than one MRSA Trust apportioned case (specimen
taken on or after the third day of admission in line with the standard national definition), as agreed
with our commissioners. The Trust had no cases of MRSA bloodstream infections in 2012-13.
This was achieved by continued MRSA screening of all patients, emphasis on hand hygiene and
scrupulous care of invasive devices.
Clostridium difficile Infection (CDI)
Clostridium difficile infections relate to patients aged two years old or more with a positive test
result recognised as a case according to the Trust’s diagnostic protocol. Positive results on the
same patient more than 28 days apart are reported as separate episodes, irrespective of the
number of specimens taken in the intervening period or where they were taken, and 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 the hospital and where the day of admission is day one.
We wanted to have zero but definitely no more than 44 cases of CDI Trust apportioned cases
(specimen taken on or after the fourth day of admission in line with standard national definition),
as agreed with our commissioners. The following graph demonstrates performance against
trajectory.
The Trust had 19 cases in 2012-13 which was a marked decrease on the 37 cases that occurred
in 2011-12. Incidence of cases in the Trust is below the national and regional averages.
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C Diff Trajectory Analysis – April 12 to March 13
Data from Health Protection Agency via IC Net
This reduction was achieved by sustaining the bundle of improvements implemented from
September 2011, which included:

Further reductions in the use of high risk antibiotics.

Daily review of patients with CDI by microbiologist and IP&CT, to support
management and isolation practice.
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Annual deep cleaning programme of wards and enhanced cleaning of rooms with
Hydrogen peroxide vapour to eradicate C diff spores.

Continued Investigation of all cases to identify leaning and drive further improvements.
medical
Improving patient safety by reducing falls and pressure ulcers
The Trust set some challenging safety targets for the year for both falls and skin care with the
expectation that education and focus on these subjects would bring us closer to our and patients’
expectation of safety.
Falls
Our aim was to achieve a 10% reduction in the number of falls in hospital that cause harm from
the level of 28 patients affected in 2010-11 (0.15 per 1,000 bed days). We achieved a 13%
reduction in the number of patients that fell as there were 25 patients harmed as result of a fall
whilst in hospital during 2011-12, equating to 0.13 patients per 1,000 bed days. This target was
achieved by increasing education to staff, use of safety crosses measuring days between falls
and introducing regular patient safety rounding.
In 2012-13 we achieved further reduction: 20 falls equating to a rate of 0.10 per 1,000 bed days.
In addition, a second aim was to achieve 95% of patients being assessed on admission and for all
patients 95% should have the appropriate falls bundle implemented in full except where the
assessment was documented within the forms used by the multidisciplinary team. We achieved
the target for risk assessment completed on admission with 95.5% and for patients at risk of falls
90.0% had the appropriate bundle implemented. Falls reduction was achieved in part by
introducing a revised assessment form, intervention bundles, education and focus on the subject.
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Data from Nursing Metrics database
Falls bundle implementation: the following graph shows that the target for appropriate care
bundle implementation was achieved in some months but not overall and work is continuing to
improve consistency across all wards. This will be led by the designated ward based Falls
Champions that have received additional training.
Falls care plan completed for patients in at risk group
100%
Target: 95%
90%
80%
70%
April 2012
May 2012
June 2012
July 2012
August
2012
September
2012
October
2012
November
2012
December
2012
January
2013
February
2013
March
2013
Data from Nursing Metrics database
Improvements Achieved:
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Implementation of the new patient falls risk assessment and evidenced based staged
bundles in all wards.
Main part of the rollout completed, with ward staff and champions being supported by
trainers from the falls operational group.
Falls Intranet page developed and launched. This contains national and local falls
information and links, in addition to the local falls policy, relevant paperwork, audit tools
and referral forms to refer patients to community services.
A series of Falls Champion training days have been run with high levels of positive
feedback.
Established robust links for other NHS, social care and private sector providers through
the Somerset Falls Network.
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To complete the ‘mop up’ areas in the roll out as these need individual modifications /
additions to the bundles due to the nature of the patients and environment;
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Patient Safety
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Patient Experience
To include the new falls process measures into the nursing metrics;
Continue to implement an on-going training plan to support the Falls Champions;
Monitor the frequency and severity of falls;
Continue to investigate the root cause of each fall that causes harm;
Investigate situation and look at improvements in linking in with community services to
ensure referral on to on-going care for falls management on discharges.
Skin Care
Our aim in respect of skin care was that we could reduce hospital acquired pressure ulcers of
grade 2 severity (superficial ulcer, abrasion or blister) or above by 50% (target 0.9% per 1000 bed
days). The 2011-12 rate was 1.14 per 1000 bed days. In 2012-13, the Trust averaged 1.26
pressure ulcers per 1000 bed days with 243 grade 2 or above hospital acquired pressure ulcers
reported. This equates to around 20 patients affected each month.
Although we did not achieve the 50% reduction, there was a sustained increase in the overall
number of pressure ulcers reported in 2012-13. There was a decrease in the number of hospital
acquired pressure ulcers however, where the average number of patients affected reduced from
19 per month in 2010-11 to 18 per month in 2011-12. For the full year April 2011 to March 2012
the overall number of pressure ulcers reported was 696 of which just under one third (218 –
31.3%) were hospital acquired.
‘Hospital acquired’ for this Trust means harm caused by pressure ulcers that occur during a
patient’s stay in Musgrove Park Hospital. The nursing quality measures introduced in 2010
provided focus on the process of assessing patients’ skin and putting in place actions to prevent
pressure damage. This resulted in an increase in the numbers reported and the accuracy of
reporting which has been sustained.
In 2012 the Matrons implemented a root cause review of every hospital acquired grade 2 severity
pressure ulcer which has enabled us to better understand the causes. Chief among these were
staff not being consistent in undertaking skin reviews and position changes. In addition the
Matrons were able to identify a number of cases where skin breakdown was unavoidable due to
patients’ conditions or patients’ preferences not to accept the preventative treatments offered.
Although this meant that we were unable to achieve our goal for 2012-13, we are more confident
that the right actions are taken from the moment patients arrive in hospital and with regular skin
review during their stay.
Rate per 1,000 bed days
The following graph reflects the attention given to this priority which included on-going staff
education and monthly validation of incident reports by Matrons which began in December 2012
to ensure correct and accurate data is recorded.
Data source: Ulysses Incident reporting database (validated)
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In addition we now know that in 2012-13 the proportion of patients in hospital with pressure ulcers
reduced from one third being hospital acquired down to one quarter. We are working with our
partner organisations in the community to alert them to the safety issues for those patients
admitted with pressure ulcers. The average number of patients in 2012-13 developing hospital
acquired pressure ulcers rose slightly to 20 per month.
Over the year we purchased additional pressure relieving mattresses and seat cushions to meet
the increasing need of our patients which is assessed regularly through the collection of individual
patient risk scores. These risk scores inform our equipment purchasing plans.
Source: Incident database (Note: This measure excludes records with no grade established.)
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Continued implementation of two-hourly patient rounding that includes skin inspection to
aid early identification of problems at pressure points such as heels and sacrum.
Education for ward staff about the key actions to take to prevent pressure ulcers.
Continued use of safety crosses to provide visual information on each ward about the
number of days since the last hospital acquired pressure sore.
Root cause analysis of every hospital acquired pressure ulcer rated grade 2 or above.
Further improvement identified:
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The Trust Improvement Network supporting a Pressure Ulcer Collaborative to focus the
attention of all professional groups on prevention.
Purchase of more pressure relieving equipment.
Sharing information with community staff to improve early recognition of pressure ulcers
in all care settings and learning from other organisations.
Involving ward staff in the investigation and learning from each case of hospital acquired
pressure ulcer.
Our aim for patients receiving sufficient food within or outside of mealtimes focused on ensuring
those who needed assistance with eating reported that they had been helped. We set a 95%
target for this. Our second target set at 100% and related to ensuring wards hold a range of
appropriate snacks and they could access hot foods day or night. These targets were set in the
context of improving assistance to patients between and at mealtimes by ensuring they could
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reach their food and drinks, by opening packaging, offering finger foods or by fully helping them to
eat where this was needed.
Help with eating
In 2012/13 the percentage of patients surveyed each month reporting they had received
assistance with eating, all or most of the time, where this was required was 92.1% against a
target of 95%. Just missing this stretching target was disappointing and the results reflect a period
Percentage
in the summer of 2012 of poorer results where the Trust experienced challenges in ward staffing
levels followed by a trend of improvement since October 2012 following recruitment.
Data Source: inpatient survey results
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Total
number of
patients
Apr -12
Numbers of patients reporting against this question each month are tabled below. Where dips
showing negative responses have occurred, results have been checked with the wards concerned
to raise the issue of ensuring assistance is offered. A further question is now being asked in the
monthly surveys to find out, if patients aren’t getting help, what sort of help they would like. The
findings from November 2012 were reviewed but nothing of note was found. Increasing numbers
of participants in most months over the year provides a more representative sample of patients.
31
31
23
18
14
26
28
48
18
58
71
121
Access to appropriate snacks
An audit of food and drink availability at ward level was undertaken in 2012. It found that out of 30
wards/patient areas, 27 (90%) demonstrated access to the standard range of snacks, fortified
drinks and hot foods. Of the 17 key food/drink items, five areas had all the items and 26 out of 30
areas audited had at least 15 items. A repeat of this audit is planned for 2013.
There were a number of gaps in equipment provision, for example seven wards did not have a
microwave. A working group of the Nutrition Steering Group has produced a list recommended
food and drink items. There is recognition of variability in ward provision for different patient
groups, which the Catering Liaison Manager will agree with individual Ward Managers.
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 Sub-groups of the Nutrition Steering group have developed work-streams to focus activity on
improvement which includes a range of teaching and learning opportunities.
 A successful Nutrition Week was led by one subgroup. Nearly 400 staff attended awareness
sessions and wards were involved in creating displays around Nutrition. Through the
campaign, entitled ‘Nutrition Early Action Taunton (NEAT), each ward was asked to pledge
their commitment to Nutrition, by signing posters displayed on their ward. Tray inserts were
created to highlight key messages to patients.
 A range of guidelines and policy were published including The Food, Nutrition, Hydration &
Health Policy; and guidelines related to specific patient groups.
 Continued review of performance in the Nutrition Nursing Metric – March 2013 performance:
89% compliance with questions related to evidence that patients’ risk of malnutrition is
assessed and appropriate actions have been implemented.
 A subgroup of the Nutrition Steering Group has been undertaking ‘Mock CQC’ inspections
involving visiting wards at lunchtime to observe practice and then interviewing both patients
and staff. Ward nurses are advised at the time of the outcome. The findings from the mealtime
visits show considerable variability between wards and these are discussed with Matrons and
ward areas with the aim sharing best practice and increasing consistency in practice.
 Training for doctors and nurses on checking the safe placement of naso-gastric feeding tubes.
 Audit of the food availability and modified diet provision on the Stroke Unit. Work is on-going to
source better breakfast options. Some improvement in snack provision has been achieved.
 The Nutrition Steering Group plans to complete a Trust wide audit on one day to ensure
patients’ nutritional needs are assessed within 48 hours of admission
 Five Mealtime Volunteers have now been recruited and trained. They will work on three wards,
as a pilot programme. A range of guidance and training has been created to support the
introduction of the mealtime assistants. If the introduction of the volunteers is successful more
will be recruited to work in other wards.
 Pictorial menus are being created to support patients with Dementia or those with
communication difficulties.
 The Ward Food Folder introduced in 2012 will be evaluated by the Catering Liaison Manager.
 The Nutrition Champions programme continues to support ward-based staff.
Our aim for this topic was to develop a screening process for dementia for all patients aged 75 or
over admitted to hospital. For those at risk we planned to use a set of tests to confirm the
diagnosis and also to establish processes for ensuring and measuring timely referral to dementia
services and specialists. The form with the screening question leads into the assessment itself.
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The screening question asks if the person has had significant problems with their memory over
the previous six months.
We achieved our aim of developing a format for screening and assessment and a system for
onward referral to specialist services. The results demonstrate success in all three parts of the
process.
Assessment of patients at risk
A target was set within the national Dementia CQUIN (Commissioning for Quality Improvement)
framework for us to achieve 90% by the year end of patients aged 75 or over admitted as
emergencies to be screened within 72 hours of admission to hospital.
Between April and June 2012 we developed a system to identify the patient group and to collect
data using the national screening question about memory loss. By fourth quarter we had achieved
66.2% of the patient group being screened which is below the target set for this quarter. It has
been accepted nationally that 72 hours gives insufficient time to test for dementia as patients are
often still too unwell for the test questions to be answered.
Data Source: Unify returns
Confirming diagnosis
A set of tests to confirm diagnosis has been agreed nationally and these are in place for use for
patients that are deemed at risk for dementia. Having set up the system for screening patients for
risk of dementia, from August 2012 we implemented the diagnostic tests and compliance quickly
rose to the level of 90%. Further support from the dementia team will determine the sustainability
of this level of compliance.
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Referring patients to specialist services
The process used to refer patients to specialist dementia services is a recommendation to the
patient’s GP at the point of discharge. We met our target earlier than expected of referring 90% of
those identified as at risk and consistently achieved 100% compliance from end of 2012.
Improvements achieved:

Quality checking notes of all admitted patients in the age group every day.

Acting for every patient admitted with a known dementia to prompt adaptations to care
and to compile a list of carers to be contacted for feedback on their experiences.

Follow up for all those discharged without screening recorded, by recalling and reviewing
the medical notes and taking action if required.

Acting on those with repeated admissions for Consultant Geriatrician review and report to
the discharge action/patient flow groups.

Inputting all completed screening into Cerner (Electronic Patient Record) and flag those
with known dementia on Cerner.

Reviewing all discharge summaries for outcome of screening i.e. do they get a diagnosis?
The Mental Health liaison nurse for Older People is following up those referred to GP for
outcome. Cerner is updated with results.
A dedicated Dementia Team has also completed (and continues training) with doctors, nurses,
ward-based dementia champions and support staff e.g. therapists, on the importance and value of
good screening and how to make it meaningful.
With a re-organisation and refocus of the Dementia Strategy Group we had a very successful
Peer Review in January 2013 where they commended the significant progress made over the
past 12 months stating ‘the impressive achievements to date of the hospital dementia team and
Strategy Group’; most notably:

The team has provided strong leadership, organisation and drive to deliver a focused
work programme;

Clearly empowered Dementia champions - to be proactive, through their support and
encouragement of a ‘can do’ culture;

The training/education programme seems robust and increasingly embedded;
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
There are examples of clear pathways and leadership;

The volunteering within the elderly care wards works well, with a clear plan for spread.
The introduction of activity and personalising bed spaces with clear ownership for testing
this change;

Many changes to the environment have been achieved with modest investment. The art
work across the hospital, the developing use of appropriate signage, the opportunities for
patients to eat away from their bed area, all indicate that the South West standard on
environment is being implemented and is making a difference to the quality of care.

Successful in our Bid as part of the ‘Dementia Friendly Community in Somerset Project’
we have been awarded £150K to make environmental changes to an acute orthopaedic
ward. The right environment for the care of dementia patients is a key part of Musgrove
Park Hospital’s strategy for being a dementia friendly hospital. This work will inform the
future design and build work of all environmental projects in the hospital and part of the
design strategy.

Roll out actions across the hospital 24/7 and to assure the progress attained is sustained
going forward.

Continue training and incorporating new areas.
Improving how well we communicate
The aim last year was to reduce the number of written complaints about communication from the
2011-12 baseline which averaged seven complaints per month.
A decrease of 1.1 was achieved to 5.9 complaints per month in 2012-13.
Number of complaints about communication
FY 2012
FY 2013
10
Average
Average
5
0
Data Source: Ulysses Complaints database
In addition to measuring complaints about communications, we continue to monitor the timeliness
of written discharge summaries sent to GPs. Averaging around 90% over the year, in March
2013, 89.6% of discharge summaries were sent within 24 hours of discharge. Where electronic
transfer is available at the receiving GP practice, this is the preferred method of information
transfer.
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Data Source: database
The National Inpatient Survey 2012 identified the Trust as being in the top twenty of hospitals for
ensuring patients receive copies of letters sent between hospital doctors and GPs. Our result for
patients reporting that they had not received a copy of this letter was 16%, half the national
average of 34%.
The Trust recognises the importance of timely and clear communications with patients and is
keen to improve its administrative systems to reduce the level of complaints and concerns raised
both by patients and staff. Our aim in 2012 was to undertake a review of administrative systems
to understand the problems, put in place changes to improve and by doing so to make processes
better for patients and staff.
The Administration Excellence Programme identified six key priorities for 2012/13:
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



Eliminate delays in clinical correspondence
Improve “customer care”
Streamline and standardise administrative processes
Reduce outpatient cancellations
Improve timeliness and accuracy of outpatient appointment letters
Improve outpatient call handling.
Improvements achieved:
One of the principle performance measures was a reduction in complaints and PALs concerns
relating to these areas. Overall, these have fallen from 73 in quarter one, to 53 in quarter two and
39 in quarter three.
In terms of written communications specifically, a number of actions have been undertaken which
has contributed to this improvement:

Completion of Medical Secretary work-force review and on-going recruitment into vacant
posts;

Increase in Apprentices and development of Advanced Apprentice role;

Revised performance framework introduced to monitor and manage typing workload;

Contact details on patient letters and website updated;

Standard Operating Procedures developed for both medical secretarial and clinical staff;
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
Improvement projects underway in Cardiology and Urology as part of Musgrove’s
Improvement Network to improve the timeliness of communicating results of
investigations to patients and GPs;

Pilot implementation of partial booking system for mutually agreeing the date of follow up
appointments with patients in Paediatrics, Vascular Surgery and Rheumatology. Phased
roll out to other specialties to be continued throughout 2013/14 in order to reduce the
number of hospital and patient cancellations;

Telephone clinic appointment letters amended to improve clarity;

Technical solution developed to identify any appointment letters generated but not printed
to ensure all letters sent patients.
A key development which will further reduce the time taken to produce letters for patients and
GPs is the implementation of a new clinical correspondence and workflow solution which is
currently being piloted in Spinal Surgery and Cardiology. The system will be put in place in every
specialty by September 2013 and will enable letters to be sent electronically to GPs. The
feasibility of offering letters to be sent securely to patients will also be explored as part of this
solution next year.
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Quality Improvement Priorities: 2013-2014
In April the Trust Board agreed the following Key Quality Improvement Priorities for 2013-14:






Improving patient safety whilst in hospital by reducing falls and pressure ulcers
Staff knowledge and meal provision
Managing emergency admissions.
Area for
Improvement
Sustaining the reduction of Hospital Acquired Infections
Why is this
important?
To ensure a safe environment where patients feel assured regarding hygiene care
whilst in hospital. Our Board and Members Council have asked for this to remain a
priority and our commissioners have set us some expectations.
What do we
want to
achieve?
MRSA: no cases
Performance
to date
Infection Type
C difficile: ideally zero but no more than 15 cases
MRSA
C Difficile
Year
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
No. of cases
36
16
8
8
1
1
0
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
66
55
48
73
37
19
The increase in C. difficile cases in 2010/11 was due to the Trust implementing a
more sensitive test that also identifies the presence of C. difficile in patients without
symptoms as well as those with symptoms. This test became the norm across all
hospitals in 2012.
Examples of
action being
taken

Early identification and isolation of patients with infections.

Monitoring of infection rates including, staphylococcus, E-Coli and other blood
stream infections, C. difficile infection and surgical site infections. Analysis and
investigation of cases is carried out to inform and drive targeted improvements.

Regular audits of hand hygiene, care of vascular devices and cleaning.

Unannounced hygiene visits to wards by a team of staff including an Executive
Director, Clinical staff and a member of the infection control team are carried out
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on a regular basis. Any areas of concern are highlighted to the ward manager at
the time of the visit and improvements put in place are reported to the Infection
Control Committee by the relevant matron.

Deep clean programme of wards.

MRSA screening of elective and emergency patients.

Restrictions on the use of high risk antibiotics and regular monitoring.
 On-going education for staff, including a dedicated Infection Control Link
Practitioner and Cannula Champion in all clinical areas. How this will
be measured
and
monitored?
Mandatory reporting of MRSA Blood Stream Infections and C difficile cases. In
addition we have a well-established Control of Infection team that monitors and
reports other cases of infection. In depth reviews of individual cases are carried out
to understand how the infection occurred and to identify any learning that may
prevent a similar infection in other patients.
How will this
be reported?
Monthly reports produced and shared within the hospital and reported to the Trust
Board.
Area for
Improvement
Improving patient safety by reducing falls and pressure ulcers
Why is this
important?
To promote an environment where patients feel safe regarding the risk of avoidable
harm occurring whilst in hospital. Pressure ulcer and falls prevention was identified
as a priority in our survey of Trust members and the public.
What do we
want to
achieve?
Falls: to accurately identify the number of falls that lead to significant harm and
reduce by 10% by implementing actions proven to prevent fracture.
Pressure Ulcers: to reduce by at least 40% the number of avoidable hospital
acquired pressure ulcers of grade 2 and above from the year end 2012-13 level.
Performance
to date
Harm type
Falls
Year
No. of cases
2009-10
2010-11
2011-12
2012-13
14
28
25
17
2009-10
122
2010-11
227
2011-12
219
2012-13
243
There was increased focus placed on formally reporting patient falls and pressure
ulcers when the nursing workforce introduced a set of measures called ‘Nursing
Metrics’ in February 2010. These metrics focus on topics felt by the profession to
reflect the quality of nursing care and include falls and pressure ulcers. This
accounts for the increases for both topics seen between 2009 and 2010.
Pressure Ulcers
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Patient Safety
Examples of
action being
taken
Patient Experience
 Purchase of additional pressure relieving equipment including mattresses and
cushions to meet changes in identified need.
 Continued use of safety crosses on each ward as visual reminder to patients,
visitors and staff stating the number of days since the last fall or pressure ulcer.
 Implementation and monitoring of formal patient comfort rounds every 2 hours
that includes checking the skin of patients at risk of developing pressure ulcers
and incorporates the basic falls bundle.
 Staff education regarding assessment and the key actions that prevent
falls and pressure ulcers.
 New falls risk assessment with associate stage bundles implemented on all main
wards and basing simple learning tools from cases where unrelieved skin
pressure caused harm.
 Reporting our figures for falls and pressure ulcers nationally using the Patient
Safety Thermometer from April 2012 will enable benchmarking against national
averages.
How this will
be measured
and
monitored?
Dedicated multi-professional groups lead on and monitor falls and pressure ulcers
which are subject to monthly reporting. In depth reviews of individual cases are
carried out to understand how the fall or pressure ulcer occurred and to identify any
learning that may prevent similar events occurring.
How will this
be reported?
Monthly reports produced and shared within the hospital and reported to the Trust
Board.
Area for
Improvement
Why is this
important?
What do we
want to
achieve?
Staff knowledge and meal provision
Nourishment is a key element in recovery from illness or surgery and maintenance
of good health. Our online survey demonstrated that the topic of food and nutrition
was a priority for high quality care and we know we need to continue improving
staff education, food availability and practice. We provide a range of nourishing
foods when patients need it and we aim to ensure that they are given the
assistance they need.
This year we want to focus on staff education and food availability. Our targets for
the year include:
80% of staff will demonstrate an acceptable level of knowledge about food
availability;
95% of wards will have a core range of snacks available;
90% of patients will report they have received help with eating all or most of the
time, where this was required.
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Patient Safety
Performance
to date
Patient Experience
27/30 (90%) wards/patient areas demonstrated access to the standard range of
snacks, fortified drinks and hot foods in 2011-12. A repeat of this audit is been
planned for 2013.
An audit of staff knowledge was not undertaken last year.
We will continue the measurement strategy started in 2012-13 for nutritional
screening on admission to hospital, nutritional care planning and the delivery of
nutritional care against these care plans. Target 90% for each parameter:

Nutritional screening for adults – 89.9%

Patients at risk have documented care plans in place for 83.4% of patients

Nutritional interventions were documented for 86.3% of patients.
In 2012/13 the percentage of patients reporting they had received assistance with
eating, all or most of the time, where this was required was 91.0% against a target
of 95%. This question remains part of our monthly survey.
Examples
action being
taken
Dedicated Nutrition Team and team of Dietitians working with patients unable to
eat normally.
Education about nutrition provided to a range of staff groups.
In 2012, a Nutrition Awareness Week was held where nearly 400 ward staff
attended an awareness update session and educational displays were created on
most wards. Also patient meal tray inserts were introduced to provide patients with
information about their nutrition.
Nutritional screening for inpatients on admission to hospital.
Regular nursing rounds to all patients at risk of malnutrition to encourage eating or
consumption of fortified drinks.
Review of catering provision – special menus for patients requiring modified texture
diets have been introduced and new patient menus are in development.
A ward food folder has been introduced on each ward offering information on food
provision and special diets, for both patients and staff to use.
Mock ‘Care Quality Commission’ inspections have been undertaken by a team of
hospital staff to observe mealtimes and the results are shared with Ward Sisters
and Matrons to focus on improvement where needed.
Role of Catering Liaison Manager has been introduced in February 2013, to work
with the wards, the catering team and Dietitians, to further improve patient food
provision, support staff education and monitor quality.
Mealtime volunteers have been recruited and trained to work on three wards
initially. This is proving helpful in ensuring those patients who need extra time to
eat their meals receive it. If successful, the aim is to roll this out across further
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wards in the hospital.
Continuous audit and monitoring.
How this will
be measured
and
monitored?
Audit of staff knowledge – target 80%;
Annual audit of wards with core snacks and foods – target 95%;
Nutritional Screening, Care Planning and Delivery of Care plans: through nutritional
metrics undertaken monthly;
Patients are asked each month if they received assistance with eating if this was
needed – target 95%.
How will this
be reported?
Inpatient survey and nutrition metrics both report position monthly to wards and
Matrons.
Report of food and drink availability and staff knowledge about food availability to
the Nutrition Steering Group.
Quarterly report to Trust Board.
Area for
Improvement
Why is this important? Caring for patients with dementia
Nationally, there is widespread concern about the care of people with dementia in
the general hospital setting. It is estimated that 25% of general hospital beds in
the NHS are occupied by people with dementia, rising to 40% or even higher in
certain groups such as elderly care wards or in people with hip fractures. The
presence of dementia is associated with longer lengths of stay (an average of
seven extra days compared to patients with similar primary diagnoses but no
dementia), delayed discharges, readmissions and inter-ward transfers. DOH 2012.
The dementia challenge was launched in March 2012 by Prime Minister David
Cameron and we are committed to transforming to a ‘dementia friendly’ hospital.
In 2012/13 there was the National Dementia CQUIN setting Acute Hospital Trusts
the target to screen for dementia in the 75 years+; and a local CQUIN to achieve
the South West Hospital Standards in Dementia Care – Level Two What do we want to achieve? In 2012 we committed the funding to set up the Dementia Team for 12 months to
the focus the action needed to implement the National Dementia CQUIN, the local
Dementia CQUIN, national audits e.g. anti-psychotic prescribing and to respond to
opportunities for improving dementia care through national funding released as
part of the Dementia Challenge Initiatives. It was our aim to put in the foundations
in place for the hospital to become a ‘dementia friendly’ hospital.
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Patient Safety
Performance to date Patient Experience
National Dementia CQUIN (screening): aiming to screen 90% of patients within
72 hours of admission.
In Quarter 4 of 2012-13 we achieved 66.2%.
Peer Review in January 2013 positive outcome with no gaps and no significant
recommendations.
A letter was received in January 2013 from our commissioners acknowledging the
concern raised nationally about the difficulties in achieving the 72 hour expectation
when many patients are still too unwell to be screened and assessed and
adjusting the expectation to 90% screened during their inpatient episode.
Examples of action being taken The aims of the dementia team to screen and assess patients; train and educate
staff; and make the environment ‘dementia friendly’ for patients, will continue
throughout 2013-14. For example, Wordsworth Ward has provided a quiet area for
patients and the Jubilee Building design has been informed by the dementia group
to ensure the new environment promotes a safe and calm setting for all patients
coming in for planned surgery and particularly for those with dementia. As the
dementia team comes to the end of their 12 month secondment into their roles
they are setting out the resources needed to continue the leadership,
implementation and evaluation.
How will this be Progress against achieving screening 90% of patients is monitored monthly
through the CQUIN monitoring meeting.
measured and monitored? The progress against the hospital’s Dementia Action Plan is monitored through the
Trust’s Dementia Strategy Group monthly meeting: this includes reporting on
leadership; training and education performance; feedback from dementia
champions monthly audits; environmental updates; and all aspects of the care
pathway.
How will this be Status on the CQUINs is reported quarterly to the Trust Board as part of the
Clinical Quality Report
reported? Status on the action plan is reported monthly via the Dementia Strategy Group
which has non-executive and executive members as a part of the membership.
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Patient Safety
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Area for
Improvement
Improving how well we communicate with patients
Why is this
important?
This area was highlighted as very important in our public survey of key priorities
to review in year. It relates to how patients feel they are treated when they attend
the hospital or are contacted by staff.
In 2012-13, in more than half of all the formal complaints received, there was
some element relating to communication or concern about staff attitude. These
complaints were often about other things, such as treatment or delays in care,
with the communication concern being one part of a bigger issue. The
experiences mentioned in the complaints included how people felt they were
spoken to face to face or by telephone, or on receipt of written communications,
for example about appointment changes.
The Trust is working hard to improve its administrative functions, including written
communications and the systems that support booking information. Staff training
is key to the success of these improvements.
What do we
want to
achieve?
During 2013-14 we will deliver a values-based training package on
communication skills for administrative and secretarial staff, linked to staff
appraisal, to address staff attitude issues and promote good customer care skills.
This will be supported by implementation of a ‘partial pending project’ for
outpatient appointments to improve bookings and a ‘theatre scheduling project’ in
year
To ensure administrative staff have received customer care training – increase
from 2012-13 baseline.
Decrease in the absolute numbers of complaints and concerns received about
staff attitude and communication in relation to the administrative staff group.
Performance to
date
High level reports about formal complaints seen regularly by the Trust Board
reflect the themes of communication and attitude as areas of concern, along with
a theme of clinical treatment, as demonstrated in the graph below.
Data from Ulysses reporting database
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Whilst a single complaint can have more than one theme, a breakdown by
themes from formal complaints shows a range of issues, as demonstrated in
Oct-Dec 12:
Examples of
action being
taken
How this will be
measured and
monitored?
Appointments (cancellations/delays)
7
Attitude of staff
5
Communication/info to patients
21
Diagnosis
5
Discharge
4
Medical treatment
17
Nursing Care
5
Operations (outcome, cancellation, delay)
7
Patients make use of the Patient Advice and Liaison Service (PALS) when
concerned about written or direct communications by hospital staff. In 2012-13
there were 49 PALS concerns and one formal complaint raised about
communication and six PALS concerns and eight formal complaints about the
attitude of administrative staff.

Spread of customer care training.

Bespoke training in specific high risk areas

Learning from complaints spread across the Trust

Patients’ stories shared with staff involved in specific cases.
To ensure administrative staff have received customer care training – increase
from 2012-13 baseline as a percentage of Trust employees.
Decrease in the absolute numbers of complaints and concerns received about
staff attitude and communication in relation to the administrative staff group.
Progress will be monitored through monthly performance meetings.
How will this be
reported?
Reported quarterly to the Quality Assurance Committee.
Area for
Improvement
Managing emergency admissions
Why is this
important?
The Taunton and Somerset NHS Foundation Trust Board has raised concerns about
the increasing levels of emergency admissions impacting on its capacity to respond
to the demand whilst still providing other services as usual. The graph from hospital
information services demonstrates the upward trend in medical emergency
admissions from April 2010 to March 2013:
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There has been an increase in emergency admissions of 12% in the last two years
and whilst flexibility in the number of beds we need is managed on a daily basis, the
impact of a further 3% increase on the previous year in medical emergency
admissions in the first three months of 2013 has resulted in opening additional beds
and using surgical beds far more frequently than expected.
This increase has caused challenges for staffing to the correct levels in terms of
numbers and skills of nursing, medical and therapy staff especially out of hours and,
in extreme pressure when multiple patients arrive at the same time, delays to patient
treatment. We have also cancelled some planned surgery to create space for
emergency patients. This situation has been recognised as a significant corporate
risk to providing all of our usual services.
What do we want
to achieve?
To provide safe and effective care for all patients admitted hospital whether as
emergencies or for planned surgery. We aim to do this by working collaboratively with
general practitioner bodies to control the number of emergency admissions, enabling
planned management of inpatient flow and improving bed and staff management. We
will continue to work with primary and social care agencies to provide timely
discharge care. The area where we can have most impact in managing patient flow is
in addressing the issues related to readmissions, rates of which have increased.

Performance to
date
For patients discharged from Acute Medical Specialties, to identify the most
commonly occurring conditions that result in patients being readmitted within 30
days and to take actions that may lead to reducing the readmission rate in each
condition.
Readmission rates for patients previously under a specialty in the Acute Medical
Directorate are increasing as demonstrated in the table below.
Year
Number
2010-11
2011-12
2012-13
1975
2187
2266
The specialties with most readmissions include Cardiology, Gastroenterology,
Respiratory and Care of the Elderly.
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Medical outlier bed days (the number of days medical patients were cared for in
surgical wards) provide a relevant measure of impact on the hospital’s usual
business. Performance to date shows a rising impact on the hospital’s capacity:
Year
Number
2010-11
2011-12
2012-13
4235
3485
5243
Surgical cancellations for organisational reasons within 24 hours of the planned
procedure provide another relevant measure of the impact of emergency admissions.
Performance shows a trend downwards from 2009-10 with an increase in January
2012-13:
Year
2009-10
2010-11
2011-12
2012-13
Examples of
action being
taken
No.
cancelled
508
493
437
504
Total
planned
admissions
36612
38409
39846
40366
%
cancelled
1.4
1.3
1.1
1.2
Development of a heart failure service to support West Somerset patients;
Remote monitoring of recently discharged COPD patients by the THREADs team;
Working with GPs to develop ambulatory care pathways for appropriate conditions eg
management of deep vein thrombosis;
The development of a Frail Elderly Care Pathway in collaboration with other health
and social care providers in Somerset, supported by our commissioners.
How will this be
measured and
monitored?
Readmission rates are monitored in the Acute Care Directorate monthly reports;
other measures are reported monitored monthly through performance dashboards.
How will this be
reported?
Reported monthly to the Trust Board
National Quality Indicators
In 2013, the Department of Health mandated hospital trusts to strengthen their quality accounts
through the introduction of mandatory reports against a small core set of quality indicators. This
includes providing comparative information to make it easier for readers to understand whether a
particular number represents good or poor performance.
The information on each topic identifies how well we performed in 2012-13, compares this with
national averages and the highest and lowest performing Trusts and includes a brief commentary
explaining our relative performance and steps being taken to improve performance. Topics are
presented within the relevant NHS Outcomes Framework domain. Data is taken from the Health
and Social Care Information Centre (HSCIC) database prepared for this section of the Account.
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Summary Hospital-Level Mortality Indicator (SHMI)
Related domain: (1) Preventing People from dying prematurely
The Summary Hospital-level Mortality Indicator (SHMI) is a more recently developed mortality
indicator. It is similar to Hospital Standardised Mortality Ration (HSMR) in some respects, in that it
expresses actual deaths compared to an expected value. In this case, ‘average’ is represented by
a value of 1.00 (not 100, as in HSMR). SHMI has been designed to overcome certain
shortcomings inherent in HSMR, most specifically the influence of coding of palliative care
patients. The index is therefore calculated using somewhat different inputs, but essentially it
provides a similar type of information. It serves as a useful comparator to HSMR, increasing
confidence in our data. Our overall SHMI over the past three years is represented in the table
below.
Rate
Reporting Period
England
(Banding)
Lowest
Trust
Highest
Trust
0.9635
October 2011 to September 2012
1.00
0.8649
1.2107
1.00
0.7108
1.2559
1.00
0.7102
1.2475
(as expected)
0.9631
July 2011 to June 2012
(as expected)
0.9450
April 2011 to March 2012
(as expected)
NB 1.00 is the SHMI average, values lower than 1.00 indicates better than average
The Taunton and Somerset NHS Foundation Trust considers that this data is as described for the
following reasons:

Continued focus on initiatives related to safety and reducing avoidable deaths in a range of
specialties.

Review of Dr Foster data by specialty and at clinician level to provide early warning of
problems in patient care.
The Taunton and Somerset NHS Foundation Trust intends to take the following actions to
improve this rate, and so the quality of its services, by regularly monitoring our outcomes through
tools such as Dr Foster and the NHS Information Centre. Where outcomes appear to be
deviating, this allows verification of validity of the result, and an early opportunity to take
corrective action.
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Percentage of patient deaths with palliative care coded at either diagnosis or specialty
level for the trust
Reporting Period
Percentage
England
Lowest
Trust
Highest
Trust
October 2011 to September 2012
0.2%
18.9%
0.2%
43.3%
July 2011 to June 2012
0.5%
18.4%
0.3%
46.3%
0.4%
17.9%
0.0%
44.2%
following reasons:

The Trust has never excluded palliative care coded deaths from its overall mortality statistics.
The Taunton and Somerset NHS Foundation Trust has taken the following actions to improve this
rate, and so the quality of its services, by

focusing on the quality of its coding practice to ensure palliative care coding is correctly
applied when this is the primary reason for admission to ensure we include all deaths in our
reported statistics. This should improve confidence in our data.
PROMS: Patient Reported Outcome Measures.
Related Domain (3) Helping people to recover from episodes of ill health or following injury
PROMs measure a patient’s health status or health-related quality of life from the patient’s
perspective, typically based on information gathered from a questionnaire that patients complete
before and after surgery. The figures in the following tables show the percentages of patients
reporting an improvement in their health-related quality of life following four standard surgical
procedures, as compared to the national average.
Groin hernia surgery
Reporting Period
Adjusted
average
health gain
England
Lowest
Trust
Highest
Trust
April 2012 to December 2012
0.153
0.090
0.017
0.153
0.075
0.087
-0.002
0.143
0.075
0.085
-0.020
0.156
following reasons:
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Patient Safety

Patient Experience
Majority of patients are treated as day cases

providing a full pre-operative assessment service to enable early identification of problems for
management prior to admission for surgery and a range of verbal and written information
about the procedure.
Varicose vein surgery
Reporting Period
Adjusted
average
health gain
England
Lowest
Trust
Highest
Trust
*
0.089
0.027
0.138
0.090
0.094
0.047
0.167
0.086
0.091
-0.007
0.155
following reasons:

There were fewer cases in the last six month period than can be reported without the risk of
patient identification. When sufficient cases are available, a figure will be reported.

Giving every patient the questionnaire at pre-assessment clinic and encouraging patients
to complete and return the PROMS form.
Hip replacement surgery
Reporting Period
Adjusted
average
health gain
England
Lowest
Trust
Highest
Trust
*
0.429
0.328
0.500
0.407
0.416
0.306
0.532
0.415
0.405
0.264
0.503
following reasons:
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Patient Safety

Patient Experience
rate, and so the quality of its services by

Giving every patient the questionnaire at pre-assessment ‘Joint Clinic’ where they receive
education about the surgery, what to expect during their recovery and how to manage at
home afterwards, and encouraging patients to complete and return the PROMS form.
Knee replacement surgery
Reporting Period
Adjusted
average
health gain
England
Lowest
Trust
Highest
Trust
*
0.321
0.201
0.408
0.316
0.302
0.180
0.385
0.280
0.299
0.176
0.407
following reasons:


Giving every patient the questionnaire at pre-assessment ‘Joint Clinic’ where they receive
education about the surgery, what to expect during their recovery and how to manage at
home afterwards, and encouraging patients to complete and return the PROMS form.
Patients readmitted to a hospital within 28 days of being discharged
Related Domain (3) Helping people to recover from episodes of ill health or following injury
Whilst some emergency readmissions following discharge from hospital are an unavoidable
consequence of the original treatment, others could potentially be avoided through ensuring the
delivery of optimal treatment according to each patient’s needs, careful planning and support for
self-care. Because of the complexities in collating data, national and local rates are reported
nationally 18 months in arrears. This is the first report that includes information about children readmitted to the Trust which show that they are broadly in line with the national average. Our adult
readmission results for 2010-11 indicate that we were significantly better than average. Our 28
day readmission index is 105% which is well within the confidence limits. There are five
diagnoses that are significantly above the expected range but these are small samples and none
has reached significance.
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Percentage of patients aged 0 - 14 readmitted to the trust within 28 days of being
discharged
Reporting Period
Percentage
England
(medium
acute
trusts)
Lowest
Trust
Highest
Trust
10.68%
10.02%
0%
13.94%
9.99%
10.34%
0%
14.44%
10.46%
10.25%
0%
17.55%
following reasons:

We do tend to accept a higher readmission rate because of our strategy to manage as many
cases as possible as ‘ambulatory’ in order to minimize overall admission and length of stay

We are aware that these rates were complicated by the reason for readmission. In this period
some children who had had planned surgery were coded as ‘readmissions’ but were actually
attending for review post-discharge.

Many of these readmissions will have been babies born at Musgrove Park Hospital and coded
as ‘readmitted’ for feeding issues.
rate, and so the quality of its services, by:

Being clearer with coding and reducing the number of ward reviews

Implementing a new community midwifery led feeding protocol and assessment to prevent
admissions for ‘poor feeding’
Percentage of patients aged 15 or over readmitted to the trust within 28 days of being
discharged
Reporting Period
Percentage
England
(medium
acute
trusts)
Lowest
Trust
Highest
Trust
10.03%
11.16%
0%
12.94%
9.74%
11.05%
0%
13.17%
10.11%
10.80%
0%
13.07%
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following reasons:

over a period of three years, the Trust has maintained an overall 28 day readmission rate of
5-15% below the national average for equivalent hospitals

this is indicative of good general care and appropriate clinical judgment with regards to patient
discharges

this is during a period of the stepwise introduction of enhanced recovery programmes in
various specialties, which would indicate that appropriate discharge criteria are being
maintained
improve this rate, and so the quality of its services, by

monitoring more specific readmission rates for various procedures and conditions, as this can
provide information about clinical teams in greater detail. This would allow for improvements
to be directed at the areas that most require them.

applying learning about the causes of readmission through the organisation as a whole, which
can further improve overall performance, including in services not found to be below par.

Staff training to ensure admission details are correctly entered when patients return for wardbased review.
Responsiveness to the personal needs of patients.
Related Domain (4) Ensuring that people have a positive experience of care
Patient experience is a key measure of the quality of care. As part of the NHS we continually
strive to be more responsive to the needs of those using its services, including needs for privacy,
information and involvement in decisions. The organisation’s responsiveness to patients’ needs is
a key indication of the quality of patient experience. This composite score is based on the
average of answers to five questions in the CQC national inpatient survey which is run in July and
August every year:
• Were you involved as much as you wanted to be in decisions about your care and treatment?
• Did you find someone on the hospital staff to talk to about your worries and fears?
• Were you given enough privacy when discussing your condition or treatment?
• Did a member of staff tell you about medication side effects to watch for when you went home?
• Did hospital staff tell you who to contact if you were worried about your condition or treatment
after you left hospital?
The score for 2012 (69.5) is an improvement on that for the previous year. National data for the
2012-13 period will be available in May 2013.
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Reporting Period
Score
England
Lowest
Trust
Highest
Trust
2011/12
68.9
67.4
56.5
85.0
2010/11
69.7
67.3
56.7
82.6
2009/10
68.3
66.7
58.3
81.9
following reasons:

The Trust scores consistently better than the national average due to the focus placed on
involving patients in decisions about their care at every stage.

In 2012 we focused on ensuring patients were informed about medication they may take
home and our score rose for this question from 44 in 2011 to 44.64 in 2012.

We also saw a slight improvement of 0.7 points from 2011 relating to who patients should
contact should they have any concerns, achieving a score of 64.9 in 2012.

Continuing to survey patients against these five questions which form part of the monthly
survey.

Increasing the numbers of patients surveyed on each ward to enable substantial numbers to
support themes for actions as well as for one-off concerns.

Focusing on groups of wards for three months at a time to provide them with rich data to
which from which to take actions to improve.

Continue monitoring the results by the Patient Experience Implementation Group which is
chaired by a patient.

Continue to ensure the results are reported to Trust Board regularly
The 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.
Related Domain (4) Ensuring that people have a positive experience of care
How members of staff rate the care that their employer organisation provides can be a meaningful
indication of the quality of care and a helpful measure of improvement over time. The NHS staff
survey includes the following statement: “if a friend or relative needed treatment, I would be happy
with the standard of care provided by this Trust” and asks staff whether they strongly agree;
agree; neither agree nor disagree; disagree; or strongly disagree. Our performance has been
calculated by adding together the staff that agree and strongly agree with this statement.
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Our results were broadly in line with last year’s rating of 74% and demonstrate that staff are loyal
and feel proud of the work they undertake despite current feelings about changes in workforce
and caseloads.
Reporting Period
Percentage
Nonspecialist
acute
Trusts
England
Lowest
Trust
Highest
Trust
2012
72%
62%
35%
86%
2011
74%
62%
33%
89%
2010
69%
63%
38%
89%
following reasons:

Work being undertaken in 2012-13 with staff within ‘Big Conversations’ led by the Executive
team where staff at all levels are encouraged to express concerns and share ideas for
improvement.

Several work-streams have arisen from these events which are supported by the
Improvement Network to ensure actions are taken and that they create improvement.

Changes nationally to the terms and conditions for non-medical staff (known as Agenda for
Change) has raised concerns among staff and for which union support has been active.

Continuing the ‘Big Conversation’ approach to engage staff in the development and
implementation of ideas.

Survey the staff regularly to obtains a ‘Pulse Check’ about their views as the Trust as an
employer.

Continue to feed back to employees the outputs of work-streams where staff have been
involved in making improvements.
Patients admitted to hospital who were risk assessed for venous thromboembolism
Related Domains (5) Treating and caring for people in a safe environment and protecting them
from avoidable harm
VTE (deep vein thrombosis and pulmonary embolism) can cause death and long-term morbidity,
but many cases of VTE acquired in healthcare settings are preventable through effective risk
assessment and prophylaxis. Incidence of VTE is an important indicator of improvement in
protecting patients from avoidable harm, and there is an expectation that patients’ risk of
developing blood clots is risk assessed on admission to hospital. This became a national
Commissioning for Quality and Innovation (CQUIN) topic for 2012-13 with the local expectation
that every clinical area in the Trust could report 90% compliance with risk assessment.
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Against the national average our performance was above target in 2012-13.
England
Lowest
Trust
Highest
Trust
Reporting Period
Percentage
October to December 2012
92.7%
94.2%
84.6%
100%
July to September 2012
93.4%
93.9%
80.9%
100%
April to June 2012
92.9%
93.4%
80.8%
100%
following reasons:

Staff are trained in the protocol for risk assessment when patients are admitted as
emergencies and also for planned procedures.

Every Directorate achieved 90% compliance with risk assessment every month in 2012-13
with the exception of the Acute Care Directorate which contains the main admission wards.
This Directorate achieved 90% for seven out of 12 months.

The Trust relies on a paper-based system to record compliance with the assessments which
can be fallible when key members of the staff who collect the data are away.

Pursuing an electronic solution to recording risk assessments from which compliance data
can be reliably obtained. This solution is expected to be in place in 2013.

Continuing to monitor the rate of assessments to meet the 95% compliance level required in
the 2013-14 Commissioning for Quality and Innovation framework.

To continue the work of a dedicated team reviewing the notes of patients identified as having
had a hospital acquired blood clot (deep vein thrombosis or pulmonary embolus) to ensure
correct preventative or treatment actions were taken. These reviews identify learning which is
fed back to clinical teams within the hospital and with community colleagues to share
learning.
Rate of C.difficile infection
Related Domains (5) Treating and caring for people in a safe environment and protecting them
from avoidable harm
C. difficile can cause symptoms including mild to severe diarrhoea and sometimes severe
inflammation of the bowel, but hospital-associated C. difficile can be preventable. Incidence of C.
difficile is an important indicator of improvement in protecting patients from avoidable harm.
The rate of cases of C. difficile infections is reported rather than the incidence, because it
provides a more helpful measure for the purpose of making comparisons between organisations
and tracking improvements over time. The national average for 2012-13 will not be published by
the Health Protection Agency (HPA) until July this year but we expect our performance to be in
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line with the national average because a national standardised testing regime was brought into
use in 2012-13 which will enable comparison with other organisations.
Reporting Period
Rate per
100,000 bed
days
England
Lowest
Trust
Highest
Trust
April 2011 to March 2012*
20.8
21.8
0.0
51.6
41.1
29.6
0.0
71.8
27.2
36.7
0.0
85.2
*2011/12 rates are based upon 2010/11 HES data
following reasons:

The lower than national average rate in 2011 reflects early adoption of the now standardised
test which identifies more cases (presence of C difficile as well as active infection).

In 2011-12 we had 37 cases of C. difficile against a local target of 44 and in 2012-13 we had
19 cases against a local target of 44.

A dedicated work-stream working in 2011 identified a bundle of actions that contributed to the
reduction in the rate from the previous year, including early isolation and better antibiotic
prescribing.

Continued focus and monitoring of cases that do occur against an aim of no more than 15
cases in 2013-14;

Continued monitoring of prescribing by clinical teams to avoid use of high risk antimicrobials;

Daily review of patients with CDI by the Infection Prevention team to support medical
management.
Patient safety incidents and the percentage that resulted in severe harm or death
Related Domain (5) Treating and caring for people in a safe environment and protecting them
from avoidable harm
At Musgrove there is a positive culture for reporting incidents. Over 8600 incidents were reported
during 2012-13. Of these, nearly half are classified as patient safety incidents.
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Data from Ulysses Safeguard Incident reporting database
Patient safety incidents reported to the National Learning and Reporting System
The National Learning and Reporting System (NRLS) collects and collates information from the
incident databases of health service providers to provide thematic review and share wider
learning about patient safety through a system of safety alerts sent to every organisation.
The Trust’s Safeguard Incident software has an automatic process for uploading its incidents to
the National Learning and Reporting System (NRLS). The upload is run at least twice monthly
and the software then reports any incidents that failed to upload, such as when they did not
include the minimum data set. If we have the required information, we correct the failed incident
report before the next upload. Therefore there is usually a small discrepancy between numbers
reported and numbers accepted.
In the table below and since 2011, there is evidence of increasing numbers of reports being
uploaded to the NRLS database.
Number Reported
to NRLS
Number Accepted
by NRLS
October 2012 to March 2013
2,858*
Data period closes 31
May 13
April 2012 to September 2012
2941**
2,342
2144
2,098
1897
1,872
Reporting Period
*NOTE – this figure is the number of incidents that have been submitted so far. The cut-off date
for the reporting period Oct – Mar is 31 May 2013. The NRLS will provide a report on this period
in September 2013.
**For the period Apr-Sep 2012 there is a discrepancy of approximately 600 incident reports that
have not appeared on the NRLS upload to date, the reason for which is being investigated. For
all other periods, numbers reported are confirmed.
following reasons:
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
The Trust has been involved in a range of work-streams led by our Improvement Network to
improve specific aspects of patient safety and to reduce incidents;

We actively encourage reporting of incidents to enable learning to be obtained.

The requirement to report all patient safety incidents to the National Reporting and Learning
Database has been challenging due to our Incident Database functionality. To overcome this
we plan to roll-out web-based incident reporting which has been piloted successfully in
Maternity and X-Ray departments since August 2012.

The changeover to Safeguard Incident Web provides workflow management and incident
reporting directly into the Safeguard Risk Management System via the Trust’s intranet, giving
easy access to the System. Safeguard Web provides an entry point that is widely accessible
so that incidents can be entered by the staff involved when they happen, avoiding delays in
reporting. Managers can access the information for which they are responsible, having a clear
view of the Incidents that have recently occurred and require action, or the risks that relate to
their areas.
Number of patient safety incidents that resulted in severe harm or death (SIRI)
The NHS National Patient Safety Agency (NPSA) provided the following definitions for severe
harm or death:
Severe – Any unexpected or unintended incident which caused permanent or long-term harm, to
one or more persons.
Death – Any unexpected or unintended incident which caused the death of one or more persons.
Number of Severe
Harm / Death
Incidents
16
4
0.2%
11
0.5%
17
0.9%
Reporting Period
% of Incidents
Reported
0.6%
following reasons:

Up to September 2012 period there has been a sustained reduction in incidents that cause
serious harm or death in line with several streams of patient safety work started in 2007.

Patient safety work-streams have focused successfully particularly on reducing serious
incidents related to delays in escalation for treatment and patient falls.
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
A range of work-streams led by our Improvement Network to improve specific aspects of
patient safety and to reduce incidents.

Improvements have also been made in the quality and general approach to investigation,
giving more credibility to the recommendations means better clinician engagement with the
improvement agenda.

Encouraging reporting and greater consistency in the rating of incidents.
Statements of Assurance from the Board
Review of Services
During 2012-13 the Taunton and Somerset NHS Foundation Trust provided, or sub-contracted,
forty-nine relevant health services:






Acute adult and paediatric care
Maternity Services
Accident and Emergency treatment
Diagnostic Services
Elective and emergency services
Cancer care and radiotherapy.
The Taunton and Somerset NHS Foundation Trust has reviewed all the data available to them on
the quality of care in all 49 of these relevant services.
The income generated by the relevant health services reviewed in 2012-13 represents 100% of
the total income generated from the provision of relevant services by the Trust for 2012-13.
Part Three of the Quality Account provides an overview of our achievements and progress within
quality indicators that have been selected by us and our stakeholders including CQUINs. The
data reviewed covers the three dimensions of quality – patient safety, clinical effectiveness and
patient experience. We indicate where the amount of data available for review has impeded this
objective.
Information on participation in clinical audits and national confidential enquiries
During 2012-13, 38 national clinical audits and two national confidential enquiries covered
relevant health services that Taunton and Somerset NHS Foundation Trust provides.
During 2012/13 the Trust participated in 92% of national clinical audits and 100% of national
confidential enquiries of the national clinical audits and national confidential enquiries in which it
was eligible to participate.
National Audit Participation
The national clinical audits and national confidential enquiries that Trust participated in, and for
which data collection was completed during 2012-13, are listed below alongside the number of
cases submitted to each audit or enquiry as a percentage of the number of registered cases
required by the terms of that audit or enquiry.
These are as follows:
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National Audit Title
Participated Coverage
Acute coronary syndrome or Acute
myocardial infarction (MINAP)
(subscription funded from April 2012)
Yes
100%
Adult critical care (Case Mix Programme
– ICNARC CMP)
Yes
100%
Bowel cancer (NBOCAP)
(Subscription funded from April 2012)
Yes
100%
Cardiac arrhythmia (HRM)
Yes
Notes
Child health programme (CHR-UK)
Yes
100%
Coronary angioplasty
Yes
100%
Diabetes (Adult) ND(A)
Yes
100%
National Diabetes Inpatient Audit (NADIA)
Yes
100%
Diabetes (Paediatric) (NPDA)
Yes
100%
Elective surgery (National PROMs
Programme)
Yes
Epilepsy 12 audit (Childhood Epilepsy)
Yes
100%
Head and neck oncology (DAHNO)
Yes
100%
Heart failure (HF)
Yes
100%
(Also known as the Child Health Clinical
Outcome Review Programme)
Inflammatory bowel disease (IBD)
Lung cancer (NLCA)
All consenting cases are
submitted
4th round data collection
started in January 2013
Yes
Yes
All eligible cases are
being submitted
100%
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Maternal, infant and newborn programme
(MBRRACE-UK)
Yes
100%
National Cardiac Arrest Audit (NCAA)
No
n/a
National Comparative Audit of Blood
Transfusion - programme includes the
following audits, which were previously
listed separately in QA:
a) O neg blood use (2010/11)
b) Medical use of blood (2011/12)
c) Bedside transfusion (2011/12)
d) Platelet use (2010/11)
Yes
100%
National Joint Registry (NJR)
Yes
100%
National Review of Asthma Deaths
(NRAD)
Yes
100%
National Vascular Registry (elements
include CIA, peripheral vascular surgery,
VSGBI Vascular Surgery Database, NVD)
Yes
100%
Neonatal intensive and special care
(NNAP)
Yes
100%
Oesophago-gastric cancer (NAOGC)
Yes
100%
Paediatric asthma (British Thoracic
Society)
Yes
100%
Yes
-
Sentinel Stroke
National Audit Programme (SSNAP) programme combines the following
audits, which were previously listed
separately in QA:
a) Sentinel stroke audit (2010/11,
2012/13)
b) Stroke improvement national audit
Notes
Previously took decision
not to take part due to
subscription costs and
limitations in reporting.
(For review within 2013)
All received
questionnaires
completed and returned
All applicable cases
submitted
Data collecting from
01/02/13
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Notes
project (2011/12, 2012/13)
Severe trauma (Trauma Audit &
Research Network, TARN)
Yes
100%
Adult community acquired pneumonia
(British Thoracic Society)
Yes
-
Bronchiectasis (British Thoracic Society)
Yes
100%
Emergency use of oxygen (British
Thoracic Society)
Yes
100%
National audit of dementia (NAD)
Yes
100%
Non-invasive ventilation - adults (British
Thoracic Society)
Yes
-
Pulmonary hypertension (Pulmonary
Hypertension Audit)
No
n/a
Adult asthma (British Thoracic Society)
Yes
100%
Carotid interventions audit (CIA)
Yes
100%
Fractured neck of femur (COEM)
Yes
100%
Hip fracture database (NHFD)
Yes
100%
Paediatric fever (College of Emergency
Medicine)
Yes
100%
Paediatric pneumonia (British Thoracic
Society)
Yes
Pain database
Yes*
Data collecting at
present
Data collecting at
present
Decision taken not to
participate due to
volume of cardiac
audits. Patient group
largely treated
elsewhere.
Data collecting at
present
100%
*Participated but not for
all 3 phases due to
service configuration /
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Notes
management changes
Parkinson's disease (National Parkinson's
Audit)
Renal colic (College of Emergency
Medicine)
No
n/a
Yes
100%
Took part in previous
years, recommendation
is to take part every
other year to allow
embedding of changes
National Audits falling outside the scope of the Trust’s services
These projects were active within the period but relate to service types other than those the Trust
provides, included for completeness:
Title
Participated Coverage Notes
Adult cardiac surgery audit (ACS)
No
n/a
The procedure is not
performed
No
n/a
The procedure is not
performed
No
n/a
The Trust does not have
a stand-alone Paediatric
intensive care unit
Prescribing Observatory for Mental
Health (POMH)
(Prescribing in mental health services)
No
n/a
For mental health
service providers
Renal replacement therapy (Renal
Registry)
No
n/a
Trust is not a specialist
centre
Mental Health programme: National
Confidential Inquiry into Suicide and
Homicide for people with Mental Illness
(NCISH)
No
n/a
For mental health
service providers
Intra-thoracic transplantation (NHSBT
UK Transplant Registry)
No
n/a
centre
Congenital heart disease (Paediatric
cardiac surgery) (CHD)
Paediatric intensive care (PICANet)
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Title
Participated Coverage Notes
National audit of psychological therapies
(NAPT)
Potential donor audit (NHS Blood &
Transplant)
Renal transplantation (NHSBT UK
Transplant Registry)
n/a
For mental health
service providers
No
n/a
Not considered relevant
as Trust is not a
specialist unit – for
review during 2013.
No
n/a
centre
No
National Confidential Enquiries with active participation during 2012-13
Name of Confidential Enquiry
Coverage
NCEPOD Sub-arachnoid Haemorrhage study
Notes
100%
NCEPOD Tracheostomy study
-
Currently underway
The Trust’s response to national and local audit findings
The reports of the national clinical audits were reviewed by the Trust in 2012-13 and the Trust
intends to take the following actions to improve the quality of healthcare provided:
Paediatric Asthma (British Thoracic Society (BTS))
The Children’s Unit has put in place actions responding to the 2011 BTS report and will use the
2012 data to verify the impact of these improvements, when published. Work to increase uptake
of the asthma care plan documentation is complete. Work is continuing to ensure consistent
provision of advice sheets, to accompany children with wheeze home following an admission. The
Trust’s guideline is under review, to ensure that clear requirements for information-giving to
parents are stated. A further structured plan is in place to respond to the Paediatric Pneumonia
National Audit, also led by the BTS.
Paediatric Diabetes
The National Paediatric Diabetes Audit reported in the latter half of 2012 and development actions
have been defined, in line with current service developments linked to Best Practice Tariff
requirements and recent Peer Review of the service. Amongst these planned changes will be the
introduction of annual clinical reviews and the introduction of point of care testing to improve
HbA1C level monitoring and improved access to / uptake of insulin pumps. The Trust’s plans
have been submitted to the Regional Network Group Chair for endorsement at the next meeting.
Heart Failure
Significant service development has been planned by the Cardiology Department within the 12-13
period to establish an Integrated Heart Failure service in Somerset. This leads from both the prior
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rounds of the National Heart Failure Audit and in respect of NICE Guidelines and Quality
Standards. This work is focused on establishing Nurse-led Heart Failure Liaison Clinics for which
a business case has been approved. A framework for Commissioning for Quality and Innovation
(CQUIN) measurement has been developed which is directly based upon the NICE Quality
Standard statements. Further rounds of National Audit will also be reviewed to assess the impact
of these changes.
Childhood Epilepsy (‘Epilepsy 12’)
Whilst many of the findings have provided positive assurance that the Trust’s service for children
with epilepsy compares favorably with national benchmarks, with credit to the work of the
Epilepsy Nurse Specialists in post, further improvements are identified in the services plans: One
particular challenge is to improve the recording of a specific epilepsy syndrome using the
recognized classification system. Provision of update training for senior medical staff is planned to
ensure accurate assessment methods are used and appropriate information is recorded. Plans
are also in place to improve consistency in the use of ECG in line with NICE recommendations,
and to enhance the rate of referral for tertiary review (to the Bristol unit).
Current developments to our arrangements for review of reports
Further national audit reports, recently including Lung Cancer and Stroke, have been reviewed at
a newly established Data Review Group. Co-ordinated by the Trust’s Governance Support Unit,
the group brings together the expertise of key people, including the Lead for Data Quality, Clinical
Quality Analyst, Head of Integrated Governance and Medical Lead for Governance. This offers an
opportunity to develop an understanding of what the audit data is telling us about quality and to
effectively direct attention to those areas requiring an improvement response.
The reports of 85 local clinical audits were reviewed by the Trust in 2012/13. Action plans are
developed for all audits where significant issues are identified and the Trust intends to take
actions to improve the quality of the healthcare provided. Amongst these are the following
responsive actions, as an illustration of the service-specific development work initiated via audit
during the 2012-13 period.
Improving the availability of suitable food (snacks) and drink options for inpatients
The Trust has assessed how well it is meeting the standards defined by the Care Quality
Commission and other agencies for ensuring snacks and drinks are available to inpatients outside
of mealtimes. The audit has provided a basis for agreement of the Trust’s own minimum
standards and communication of these expectations throughout the hospital, engaging ward
managers. The developments will continue into 2013.
Evaluating the Trusts success in establishing a new Binge Eating Disorders Group
Lead by the Obesity Dietician with input from a clinical psychologist, the project measured
outcomes for attendees at a new support group for people living with Binge Eating Disorder. The
development was part of the Trust’s implementation of the NICE Clinical Guideline for obesity
interventions. Whilst improvements were demonstrated in terms of patient’s mental health status
and binge eating habits, opportunities to refine the service and improve uptake were identified.
This included arranging group meetings in the evening and improving screening to better detect
patients most likely to benefit. Further measurement is planned into 2013.
Assessing the use of contrast media in pelvic radiotherapy scans
The radiotherapy team, based within the Beacon Cancer Centre, has undertaken an assessment
of contrast use when performing pelvic radiotherapy scans. The findings support the use of the
contrast as a useful element of scanning for this patient group. It has additionally provided a basis
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for it to now also be used for rectal radiotherapy scans. This extended use will then be further
audited to assess usefulness as a means to plan appropriate treatment.
Auditing the operation of the Trust’s protocol for Emergency ENT ward attenders & ENT
emergency clinic provision
The Ear, Nose and Throat consultant team wanted to assess the provision of adequate clinic
capacity. The audit provided the information needed to initiate uplift in capacity to three clinics a
week and to provide a Junior Doctor-lead emergency access clinic as a new development.
Assessing patient experience, while receiving treatment at the phototherapy unit
The Junior Sister Leading the phototherapy service recognized that capturing feedback about
patient experience was an integral part of continually improving quality. Even though overall the
feedback has been extremely positive, there are some areas where improvements have been
identified: These include improving the information given to patients about their prescribed
treatment. In response, two leaflets have been produced, to be sent out with the routine
correspondence. More accurate measurement pre and post treatment has also been introduced,
allowing improved evaluation of treatment effectiveness. Further developments to the clinical
environment are being explored and follow up appointments are now given to patients on their
last treatment session.
Ensuring national guidance is followed in Neuro-rehabilitation
Actions leading from an audit of the management of spasticity included production of patient
information, to be given ahead of the treatment with botulinum toxin (‘Botox’) injections. Remeasurement is planned for 2013.
Information on participation in clinical research
Taunton and Somerset NHS Foundation Trust’s main contribution to the national Research and
Development (R&D) strategy lies in the recruitment of patients into externally-funded and
externally-led multi-centre trials, and other well designed studies, in particular those adopted on to
the National Institute of Health Research (NIHR) Portfolio. Our overall ambition is to provide a
wide ranging, and sustainable research infrastructure and vibrant research culture that maximises
the opportunities for all patients to enter research projects relevant to their particular condition.
The number of patients receiving NHS services, provided or sub-contracted by the Trust in 201213 that were recruited during the period to participate in research approved by a research ethics
committee was 1581 (NIHR Portfolio). This is a 58.1% increase on the plan of 1000 set out in last
year’s report. Although overall a lower number than in 2011/12; as noted in last year’s report the
2011/12 figure of 1970 was skewed by one very high recruiting study that represented
approximately 70% of the total.
The number of NIHR portfolio studies that recruited patients in the period has consistently
increased year on year over the last five years and increased by 15.0% from the 80 reported in
2011/12 to 92 in 2012/13. This increasing participation in NIHR portfolio clinical research
demonstrates the Trust’s commitment to improving the quality of care we offer and to making our
contribution to wider health improvement. This is largely facilitated through our clinical trials unit or
dedicated research-nursing staff embedded in clinical areas.
During the reporting period the Trust used national systems to manage the NIHR portfolio studies
in proportion to risk. The monthly median time to complete the risk checks using these systems
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was continuously within the NIHR’s monthly 30 day target for which the Trust was consistently
RAG rated green by our local NIHR Comprehensive Local Research Network (Western CLRN).
The Trust’s Critical Care research team won an award for ‘best validated data’ from the Sponsors
of one of the clinical trials they are participating in known as ProMISe, which is comparing
treatments for emerging septic shock. Unlike the foregoing this is pleasingly a measure of quality
as opposed to quantity.
We continue to host the Taunton and Somerset Research & Development Consortium, which
provides a research management and governance service to both the Trust and to NHS
Somerset (now Somerset Clinical Commissioning Group), and facilitates a link between primary
and secondary care research, particularly in the respiratory and cardiology areas. The Trust also
hosts the coordinating centre of the NIHR Research Design Service – South West.
Information on the use of the Commissioning for Quality and Innovation (CQUIN)
Framework
A proportion of the Trust’s income in 2012-13 was conditional on achieving quality improvement
and innovation goals agreed between Taunton and Somerset NHS Foundation Trust and
Somerset Primary Care Trust, through the Commissioning for Quality and Innovation payment
framework.
In 2012-13, the anticipated income, conditional upon achieving the quality improvement and
innovation goals, was £1,100,000. Although in 2011-12 the Trust and commissioners had agreed
quality and improvement topics, there was no financial incentive agreed for that year.
Key leads were identified for all of the indicators and a monitoring group was established to
review progress on a monthly basis.
The Trust’s overall compliance is monitored by
commissioners and discussed in detail at the quarterly clinical quality review meetings. Good
progress has been made across all areas.
Information relating to registration with the Care Quality Commission (CQC)
The Care Quality Commission is the independent regulator of health and adult social care
services in England. They also protect the interests of people whose rights are restricted under
the Mental Health Act.
The CQC carries out their responsibilities by



Driving improvement across health and adult social care
Putting people first and championing their rights
Acting swiftly to remedy bad practice

Gathering and using knowledge and expertise, and working with others.
Full information on the CQC can be found on their website.
Taunton and Somerset NHS Foundation Trust is required to register with the Care Quality
Commission, and our current registration status is registration with no conditions.
The Care Quality Commission has not taken enforcement action against Taunton and Somerset
NHS Foundation Trust during 2012-13.
The Trust has participated in a periodic review by the Care Quality Commission which visited at
the end of July / beginning of August 2012 for a three day inspection to assess the Trust against
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six key Outcomes. The inspectors visited 12 wards and four clinical departments and the Trust
was found to be meeting all of the required standards, with no compliance actions required.
The Outcomes reviewed were:
Outcome 01: People should be treated with respect, involved in discussions about their care and
treatment and able to influence how the service is run;
Outcome 04: People should get safe and appropriate care that meets their needs and supports
their rights;
Outcome 07: People should be protected from abuse and staff should respect their human rights;
Outcome 14: Staff should be properly trained and supervised, and have the chance to develop
and improve their skills;
Outcome 16: The service should have quality checking systems to manage risks and assure the
health, welfare and safety of people who receive care;
Outcome 21: People's personal records, including medical records, should be accurate and kept
safe and confidential.
As part of the inspection, the CQC followed up on issues relating to Outcome 21 (record keeping)
that had been previously flagged at an inspection in March 2012 relating to the termination of
pregnancy service. The Trust had been required to take some actions to ensure compliance and
the inspectors confirmed that these had been completed satisfactorily.
Information on quality of data
The Trust is committed to ensuring that the data we use to measure our performance is accurate.
We have an Information Governance Steering Group that receives and monitors information on
data quality. This group is supported by a specific Data Quality Steering Group with the remit to
coordinate all data quality activity into a Trust-wide framework. The Trust will be taking the
following actions to improve data quality:
1) Ensuring core training is carried out to improve the quality of the data collected to:

Provide the foundation for a programme of monitoring and improvement

Establish consistency with NHS data definitions and use of information

Support the information governance agenda.
2) Strengthening the data quality process by creating a centralised, prioritised data quality
issues log and by re-focusing the existing Data Quality team on the top priorities.
3) Through a dedicated communications plan, raising awareness throughout the organisation on
the key data quality issues and the impact they have.
Taunton and Somerset NHS Foundation Trust submitted records during 2012-13 to the
Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics which are included
in the latest published data. The percentage of records in the published data:
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- which included the patient’s valid NHS Number
was: Making the most of Musgrove
Accident and
Emergency
care Admitted
Patient
Care Outpatient
Care % of valid NHS Numbers received from BT 98.56
99.43 99.83
% of valid NHS Numbers sent to SUS 99.23
99.84 99.94
% of valid GP Practice Codes received from BT 100
100 100
% of valid GP Practice Codes sent to SUS 100
100 100
- which included the patient’s valid General Practitioner Code Data Source: Information Centre Data Quality Dashboard (figs based on Apr-Feb 12/13 SUS
data).
Compared to the previous year the percentage of valid NHS numbers received from BT has
remained at around the same level, whilst the percentage of valid practice codes has fallen
slightly. The percentage of valid NHS numbers submitted to SUS has improved slightly, whilst the
percentage of valid practice codes submitted to SUS has remained at 100%.
Compared to the previous year this shows an overall improvement for valid NHS numbers from
the previous year which were

89.3% for accident and emergency care

97% for admitted patient care

98.9% for outpatient care.
Information Governance
Taunton and Somerset NHS Foundation Trust’s Information Governance Assessment Report
overall score for 2012/13 was 85%, and was graded green with a rating of satisfactory.
The Trust was in the top thirteen of 161 Trusts for compliance with these standards.
Clinical Coding error rate
The Trust was subject to the Payment by Results clinical coding audit during the reporting period
by the Audit Commission in August 2012. The locally determined specialty for review was Oral
Surgery, with half from the admitted patient episodes and half from the outpatient file. The
selection was taken from the data submitted to the Secondary Users Service and the results are
as below.
Regarding the admitted patient audit the headline results demonstrate above 90% compliance
across all standards with the exception of the secondary procedure coding. This can be
explained by a misunderstanding of the National Standards around laterality coding for Oral
Surgery.
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As for the outpatient audit, the episodes audited were only just within the time where the
outpatient coding had started in this Trust, and therefore the sample available to the auditors was
too small to show an accurate position.
As before, these results should not be extrapolated further than the actual sample audited, and
work has already been undertaken to improve on the lower scores.
Taunton and Somerset NHS Foundation Trust was subject to the Payment by Results clinical
coding audit during the reporting period by the Audit Commission and the error rates reported in
the latest published audit for that period for diagnoses and treatment coding (clinical coding) was:
Area audited
% of
episodes
correct HRG
(Healthcare
Resource
Group)
Oral Surgery
APC
Oral Surgery
Outpatient
% Procedures coded
correctly
Primary
Secondary
92.0
89.8
70.0
N/A
100.0
N/A
% of spells
correct HRG
(Healthcare
Resource
Group)
% Diagnoses coded
Primary
Secondary
91.9
92.1
80.8
82
N/A
N/A
Taunton and Somerset NHS Foundation Trust will be taking the following actions to improve data
quality:
Recommendation 1
Address training needs for existing staff.
Recommendation 2
Introduce arrangements for new coders that provide adequate support
and monitoring of their output to ensure appropriate data quality is
maintained.
Recommendation 3
Re-audit laterality in light of improved approach to using world dental
federation notation.
Recommendation 4
Ensure the outpatient procedure policy is fully mandated across
outpatients and ensure the accountability for adhering to the new
procedure coding policy is clearly defined within each clinical department.
Recommendation 5
Improve the existing procedure coding policy so that it provides specific
guidance for each individual clinical area, including maxilla-facial and oral
surgery.
Recommendation 6
Clearly define “shared care” and “multidisciplinary” clinics and update the
coding policy to cover the correct use of the X62 assessment code to
identify this activity.
Recommendation 7
Clearly define and implement a policy on how to identify the correct
treatment function codes of clinics within oral surgery (140) and maxillofacial (144), supporting clerks in implementing this correctly; and review
processes to support accurate treatment function code allocation in other
clinical areas.
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Part Three
Other information
As this report has shown, the safety of our patients and the quality of care is of paramount
importance to all who work in the Trust. This section provides an overview of the quality of care
offered by The Trust and some of the work we are currently developing.
Improvement Network
Since the launch in February 2011, the Improvement Network has been developing the capacity
and capability of Musgrove staff to make improvements in the way we deliver care for our
patients.
The Improvement Network uses a ‘collaborative’ approach which is to bring teams together so
that there is joint sharing and learning and the opportunity to ‘cross-pollinate’ ideas within the
Trust. The focus is strongly linked into the strategic aims of Musgrove which is measured by:



95% of our patients rating the care they receive at MPH as excellent
Zero avoidable harm to patients
Reference costs for are below 90.
Improvement Network – Wave 1
March – October 2011
Wave 1 brought together most of the improvement projects within Musgrove at the time, these
can be divided into innovation e.g. dementia care, piloting e.g. Enhanced Recovery in Colorectal
Surgery, and spreading e.g. Acute care –Sepsis. 11 out of the 12 teams had demonstrable
improvements
Improvement Network –Wave 2
January – July 2012
This wave focused on spreading the principles of Enhanced Recovery to other surgical specialties
both within both the elective pathway – micro-discectomies, pacemaker insertion, lower limb
amputations and gynecology surgery, and within the emergency pathway – fractured neck of
femur
Improvement Network –Wave 3
June 2012– February 2013
Two Big Conversations were held in the summer of 2012, which were attended by over 350 staff.
Based on what staff said at these events 12 ‘quick wins (which would impact on both patients and
staff) were identified and successfully implemented. Six enabling projects, which were set up to
look at solving some of the more complicated issues that affect staff was launched, as well as the
‘first 10 teams’ who have been working in their own areas to improve both patient care and staff
satisfaction.
Improvement Network- Wave 4
March –December 2013
As part of this wave, there will be both a collaborative which will be focus on the challenge of
eradicating hospital acquired grade 3 and above pressure ulcers at Musgrove Park. This is due to
be launched on March 13th, and will have all adult inpatient wards represented. In addition 10
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frontline teams will start their journey on patient and staff improvements. The teams are listed
below:
COPD and Pneumonia care bundles Surgical move to Jubilee Building Radiotherapy workforce
Critical care outreach – the future Smoking on Musgrove site Dunkery Ward
Diabetes inpatient care Gould Ward Nursing documentation Centralized cleaning services
The Leadership Talent Programme
We reported last year on the development of a leadership programme. Staff members are our
biggest resource and greatest asset and it is, therefore, important that we use their skills and
expertise in the best possible way. Phase 2 of the ‘Leadership Matters Programme’ started in
September 2012 with 60 senior managers participating.
Over the two years of the programme, we have put through 110 senior managers of which 41
have been Senior Consultants which equates to 37% of the cohort. The programme continues to
be a great success with this year, the coaching element of the programme being extended from 3
to 6 sessions. In May 2013 a middle management programme will be starting to equip the middle
managers within the Trust with the leadership skills required to deal with the challenges of
working in a modern healthcare organisation. This programme will be a platform for those leaders
within the Trust wanting to continue to the senior leadership programme.
In addition to the formal leadership programme, a regular development programme has been in
place for ward sisters and clinical team leaders.
Listening to Staff
Musgrove introduced ‘Schwartz Rounds’ in November 2011 with support for the first year from the
Kings Fund. The rounds introduce a structured monthly one-hour forum for staff from all
disciplines to discuss the human and emotional side of clinical care. These rounds are an
opportunity for all who attend to participate in facilitated discussion. They provide a supportive
space for staff to reflect on the challenges of providing care to patients and their families.
So far we have held 10 rounds with about 280 attendees from all disciplines of which 33% of
attendees were from Nursing and Midwifery, 15% from Medical and Dental, 30% from therapy
staff and 22% from other staff groups. We have seen rounds presented by The Chief Executive,
the Medical Director as well as Specialist teams and the rounds have covered many different
topics from uniting together as a team, through to breaking bad news. The feedback from the
rounds is always really positive with 49% of attendees having attended four or more of the rounds
and people stating that they have found the rounds useful and it has helped them to reflect.
Staff Survey 2012
The 2012 NHS Staff Survey shows that the overall staff engagement survey result for the Trust
has risen from 3.64 in 2011 to 3.74 in 2012. This is better than average compared to other acute
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trusts. Alongside the engagement score the Trust is also placed in the top 20% of trusts on the
following:



Effective team Working
Support from immediate line managers
Staff reporting good communication between senior management and staff.
All of the above have been supported by the work that has taken place and started with the ‘Big
Conversations’ that were held in 2012 where Executives and staff meet to share staff concerns
and to develop work-streams that address the issues. The Improvement Network structure then
supports and monitors the teams’ progress and enables feed-back to the wider organization.
Patient Safety Walk Rounds
We continue our programme of patient safety walk rounds within the hospital. All Executive
Directors are invited to participate, demonstrating top level commitment to patient safety and
experience. This process enables front line staff to share best practice and celebrate successes
in their clinical area. It is also an opportunity for the teams to discuss patient safety issues that
cause concern to the team and to work on actions to resolve the concerns. On average there are
two walk rounds achieved each month. The whole process impacts on and improves
communication between Ward and Trust Board. Feedback comments from all involved have
been positive. Actions derived from the Walk Round are followed up within a three month window.
Patient Experience - Learning from Concerns and Complaints
Feedback from our patients and their families is very important. This helps us to continuously
learn and improve what we do. During the year we received 247 formal complaints and 1,349
concerns which were raised through the Patient Advice and Liaison Service (PALs).
All of these concerns are investigated and feedback given to the person who raised the concern,
this includes setting out what we have learnt and any changes made as a result of the concerns
raised.
Notable progress and achievements during the year:

The Trust has participated in a project with the Patients Association seeking feedback from
patients and relatives who have raised a formal complaint. This feedback has significantly
helped the Trust to better understand where we need to improve our complaint handling.
This year has seen a decrease in formal complaints received by 37% compared to last year
and an increase in the number of PALs concerns. Staff across the hospital and in PALs have
worked hard to address concerns proactively at the time and to be responsive to any
concerns raised.

On the 23 January the new “front of house” PALs/information office was opened in the Old
Building. This provides patients, families and the public with an accessible point of contact for
advice and support. Alongside this new leaflets and posters have been produced which
clearly brand PALs and make them more distinct from other information.

Working in partnership with the Patients Association the Trust was fortunate to have the
opportunity of training provided by the Patients Association to staff directly involved in the
investigation and resolution of complaints.
The Parliamentary and Health Service Ombudsman provides an independent complaints handling
service for a range of public bodies. Should any of our complainants be dissatisfied with the
handling and outcome of their complaint they have the right to request that the Ombudsman
undertakes an independent review of their complaints. We ensure that every complainant is given
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information about the role of the Ombudsman. During the year the Trust had 9 new cases referred
and the following decisions were made by the Ombudsman:

2 Local resolution was achieved

3 Ombudsman declined to investigate

1 case withdrawn

3 at time of report being assessed.
The following are just a few examples of the learning and improvements we have made:

One outcome of a complaint in A&E has been to improve the environment for patients
particularly around removing odours as it has been reported that cubicle fans can be
insufficient to clear the air.

Development of volunteer roles to support staff in improving information and support available
to patients in areas such as out-patients.

Learning from a patients discharge and feedback received, the policy for management of
those patients diagnosed with a heart attack has been amended by the Cardiologists.
Quality Indicators 2012-13
The following table provides information by month about our compliance with the CQUIN
framework (Commissioning for Quality Improvement and Innovation). This is followed by a report
on other indicators we use to measure patient safety, clinical effectiveness and patient
experience.
For each section in the table, the upper row indicates the target and the colour indicates whether
we met the target (green) or did not achieve it (red). Reporting on the CQUINS with a red rating:

In the responsiveness to patient needs CQUIN, although we improved our score from 2011 by
0.6 points in the National Inpatient Survey, we missed improving by the 0.8 points required.

In dementia screening and assessment, although we did not achieve the 90% target each
month in Quarter 4, the trajectory shows a pattern of improvement since they began in the
summer with a slight dip in February for assessment.

The Nutritional CQUIN scores dipped in the second half of the year and work is on-going to
improve compliance through additional training. In contrast, the patient survey result shows
improved compliance with patients receiving assistance to eat if they required this.

End of life care training was on trajectory with the expectation that numbers trained would
meet the year end expected level.
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In the CQUIN report that follows, details are reported for topics that have not been mentioned so
far, or reported in less detail elsewhere in the Quality Account.
CQUIN 2012-13 report
Patient Safety Thermometer
In 2012-13 this new nationally mandated CQUIN was implemented across the organisation. It
requires data to be collected on every inpatient in the hospital on one day each month. Safety topics
in the ‘thermometer’ include recording information about pressure ulcers, falls, venous
thromboembolism and catheter-related urinary tract infections. The ‘thermometer’ is a national
electronic database that aggregates reports from the hundreds of hospitals using the tool and enables
comparison of results against national averages.
We set a programme for rolling out the ‘thermometer’ across the hospital by the end of July and have
been reporting 100% of ward areas each month since August. This meets the CQUIN target for 2012.
The average rate of patients assessed as ‘harm free’ in the six months since August is above 92%.
This is in line with the national average reported in September 2012 of 91.3%.
In 2013-14 monthly reporting will continue with a trajectory to reduce the total level of harms related to
pressure ulcers in particular agreed with our commissioners as part of the year’s CQUIN contract and
as part of a Somerset-wide approach to reducing the incidence of pressure ulcers in the community
as well as in hospitals.
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Anti-psychotics Prescribing
This CQUIN aimed to ensure safer prescribing and management of patients with behaviour and
symptoms associated with dementia. The objectives include ensuring prescribing is appropriate for
the patient and reviewed within the correct timescales including timely communication with the
patient’s GP about review. Data collection is on-going in this audit and results will be reported once
they are available.
High Impact Innovations
Three topics were identified in the CQUINs framework two of which aim to reduce the need for face to
face contacts between patients and doctors and one that supports best practice for patients
undergoing high risk surgery. Progress in all three topics is expected to continue through 2013-14.
Use of Assistive Technology
Assistive technology (equipment that monitors a range of parameters such as blood pressure, weight,
heart rate etc) placed in patients’ homes can help them to reduce the need for admission to hospital.
This is undertaken through remote monitoring by a care manager in the community. Our initial
engagement this year has been via the COPD team advising community matrons about patients with
chronic breathing problems who may benefit from remote monitoring, helping the patients to manage
their own conditions and reporting signs and symptoms earlier that indicate potential deterioration in
their condition. This enables early interventions to be made. It is anticipated that the COPD nursing
team may take on a role as care managers in 2013-14.
Advice and Guidance
For many patients a GP referral to see a hospital doctor can be better managed by use of technology
at the hospital to better support patients at home, such as providing advice and guidance by
telephone, fax or email. The CQUIN for this recommended testing the process to assess the impact.
Across the three specialties involved, 26% of referrals were managed successfully in this way.
Patient Safety in high risk surgery
This innovation relates to monitoring a patient’s fluid balance during and immediately after surgery
using a dedicated monitor. We have developed a system for recording the frequency with which
patients are monitored in this way and identified the relevant conditions where this is appropriate.
Improved Planning for End of Life Care
The focus for this topic related to staff training in advanced care planning and an audit of use of the
care pathway, patients dying in their place of choice and survey of carers’ experiences including the
provision of written information after death and communication with GP/Primary Health Care Team
after death. Doctors, nurses and health care assistants from 10 key areas where deaths were more
likely to occur, were targeted for training this year. We aimed to have trained 448 staff by end of
March 2013 which represents 90% of those grades of staff in these areas. By the end of February
2013, 355 of the 448 had been trained with a plan to train 140 more in March 2013 which will take us
above target.
New for 2013-14 are topics agreed with our commissioners, some of which are national
requirements and all of which are intended to drive improvements in patient care. All topics will be
subject to incentive payments depending on the level of achievement. Topics include:
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 Implementing the Friends and Family Test

Harm reductions and incidence as measured by the patient safety thermometer

Improvements in dementia care

Risk assessing for and understanding venous thrombotic events (blood clots)

Improving communications about outpatient consultations and results and with GPs

End of life care actions

Care of patients with diabetes to reduce the incidence of foot surgery

Management of patients with problems related to chemotherapy

Reducing the number of healthcare acquired pressure ulcers

Developing a care pathway for the frail elderly.
Results from these topics will be reported in next year’s quality account.
Patient Safety
Safe discharge from hospital
The transition between hospital and home is an area of care for which a dedicated Discharge Action
Group leads and monitors how we are doing. It is essential to ensure discussions are held with
patients, and with family or carers where appropriate, about discharge to promote a safe transition
and that these discussions are recorded. Evidence that discharge has been discussed with the
patients and/or relatives has remained around 80% for the year, as measured by monthly review of
notes, whilst in the monthly patient survey it has been between 60-70%.
Data source: Nursing & Midwifery Metrics
To encourage discharge home earlier in the day and at weekends once patients are fit, all wards
have targets for percentages of weekend discharges and discharges before 2.00pm. Most wards are
meeting these targets on a regular basis.
The focus this year from the discharge group has been on improving discharge to community
hospitals, nursing and residential homes. A nursing home manager now attends the discharge group
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so that actions and issues can be worked on jointly and representatives from the Trust attend care
home manager meetings to work with them on improving processes.
There is anxiety about how the continued changes within adult social services will impact on the
Trust’s ability to access appropriate social and on-going nursing care and we are working with the
commissioners to ensure our views are represented on these issues.
All patients with a length of stay of over 10 days are reviewed by senior nurses and social workers on
a weekly basis to ensure that any blockages to discharge are identified and dealt with.
The focus for the coming year will continue in these two areas with more work on readmissions to
ensure that discharge practices are not affecting this. Complaints about discharge issues as well as
comments from primary care, social services and care homes are also now monitored to ensure that
problems are not developing.
Right medicine at the right time
Medicines reconciliation on admission
Ensuring that patients continue to receive the medicine they take at home whilst in hospital is
extremely important when patients have pre-existing medical conditions. We continue to ensure that
such medication is logged and understood as early as possible when they are admitted to hospital.
Our pharmacy has systems to achieve this for all patients.
Local Target:
95% compliance
Actual 2008-09
Actual 2009-10
Actual 2010-11
Actual 2011–12
90% compliance
94% compliance
92% compliance
93% compliance
Actual 2012-13 95% compliance
Medicines before surgery
Patients often need to fast in the period before surgery and some medications need to be withheld;
however it is important to ensure that necessary medicines are not withheld inappropriately. A project
to ensure patients receive appropriate medications before surgery concluded in 2012-13 having
achieved a 69% reduction in the number patients with medicines inappropriately withheld. The current
level of assurance identifies missed doses as an occasional event. The following chart shows the
number of patients audited and with one or more missed doses of prescribed medication due to
inappropriate clinical reason in the pre-operative period on five surgical wards from August 2010 –
February 2013.
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Data Source: Pharmacy Audit records
Prescribed Medicines
It is also important that patients on all wards receive their medications as prescribed. Each month we
review prescription charts on every ward to check that a range of standards are met that include
identifying and understanding the reasons for any omitted drugs. Our target is 95% compliance and
overall we have consistently bettered this level over the year.
Antimicrobial prescribing
Safe and effective use of antibiotics is essential to ensure appropriate management of patients with
infection and to minimise bacterial resistance to antibiotics. Since 2004, a multi-professional
antimicrobial prescribing group has led and monitored actions related to safe and effective
prescribing. Involving Consultants from every Directorate, dedicated antimicrobial pharmacists,
nurses and the infection prevention team, a range of activities are undertaken which contribute to
successful ‘antimicrobial stewardship’.
In April 2011 the group launched an antimicrobial prescribing ‘bundle’ of actions focusing on
prescribing documentation and compliance with guidelines. Both aspects are monitored monthly and
results are reported to the Directorate leads. Compliance with prescribing guidelines is consistently
above 90% and documentation compliance has almost doubled to 70%. In addition there are four
antimicrobial ward rounds each week across medical and surgical wards supporting the care of
patients treated with broad spectrum antibiotics. Each month 150 – 200 prescriptions are reviewed;
results consistently show more than 90% patients have a clinical need for the antibiotics prescribed.
Where this need is not identified, the antibiotic is stopped and teaching is provided to the prescriber.
These achievements are shown in the next graph.
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Medicines Information
To help patients before coming into and at the point of leaving hospital, this year we introduced a
leaflet about medicines. It answers commonly asked questions and provides advice about bringing
medicines to hospital, how to get more and what can be expected regarding taking medications
home. It also tells patients how to get more medicines information once they have left hospital. The
National Patient Survey 2012 result identified a reduction in the percentage of patients reporting not
being given completely clear written/printed information about medicines at discharge shows we have
improved, decreasing from 34% in 2011 down to 25% on 2012 which is broadly in line with the
national average of 26%. In the national survey we also improved our score for patients reporting
being told about medication side-effects to watch for when they went home, going up from 44 in 2011
to 46.4 in 2012.
Control of infection:
Hand washing
A key component in the reduction of infection is thorough hand hygiene by our clinical staff. This is an
important issue for the Trust and all our patients. Patients are encouraged to challenge staff if they
have concerns and they also will report this through our Patient Advice and Liaison Service. It is an
area that we will continue to focus on and monitor.
Monthly Hand Hygiene compliance audits are carried out by all areas. In addition in 2012-13, the
infection control nurses undertook hand hygiene validation audits against which we check how well
the data is collected. Results are fed back to matrons and the wards.
Local Target: 95% compliance
Actual 2009-10: 88% compliance
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Norovirus
Noroviruses are a group of viruses which are the most common cause of infective gastroenteritis in
the UK, are highly infectious and cause regular outbreaks in the community and hospitals. Norovirus
outbreaks can occur at any time of year and are more common in the winter months with hospital
outbreaks often leading to ward closure and major disruption in hospital activity.
Between October 2012 and April 2013 there were 15 norovirus outbreaks in the Trust resulting in 10
whole ward closures and 5 bay closures. A total of 119 patients were reported as affected. Overall
632 bed days were lost. This was a marked decrease in the number of closures in the year 2011/12
when there 31 whole ward closures, 3 bay closures and a total of 384 patients affected.
Outbreaks were managed robustly in line with the Trust’s Management of Norovirus policy and the
Guidelines for the management of norovirus outbreaks in acute and community and social care
settings’ (DH Norovirus Working Party December 2011).
Clinical Effectiveness
Hospital Standardised Mortality Ratio (HSMR)
HSMR is a national measure which compares the actual number of deaths occurring in a hospital
against those in other hospitals with similar patient admissions. A value of 100 represents a match of
actual deaths compared to what would be expected; a value below 100 indicates better performance
(fewer deaths than expected). Death rates inevitably fluctuate over the short term, which means that
observing them over longer periods of time (6-12 months) provides a better perspective of genuine
trends.
Mortality rates are also influenced by other factors than care quality (population demographics, hospital
case mix, palliative care arrangements), which makes interpreting and comparing them difficult.
Nevertheless, they are widely used and such we scrutinise them to provide early warning clues about
problems in our Trust.
Trust results - discussion
The following graph illustrates our quarterly overall HSMR (preceding 12 month period) over the last
three years. Our value has consistently been below 100 on average. This provides a relatively high
degree of confidence that our overall mortality performance compares well to the rest of the country, and
that we are maintaining this standard consistently. It should be noted, though, that small variations are
not necessarily accurate reflections of changes in our standard of care – these are statistical
representations, with certain inherent errors, and are most valuable to detect major deviations or trends.
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Data source: Dr Foster
NB 100 is the HSMR average, rating lower than 100 represents better than average
Apart from providing overall mortality rates, it is possible to extract more specific mortality rates, for
instance for certain diagnoses, procedures and admission times. It has been noted that patients
admitted over weekends have recently appeared to have a relatively higher mortality rate than those
admitted during the week. As there is no immediately obvious explanation to this, a review of notes of all
patients that died following a weekend admission from September to December 2012 is underway.
Detection of deviations
Performance indicators such as SHMI and HSMR, including their ability to examine specific subgroups
of patients, are useful to provide early warning of problems in patient care. For this reason, the Trust
regularly monitors our outcomes through tools such as Dr Foster and the NHS Information Centre,
providing assurance. Where outcomes appear to be deviating, this allows verification of validity of the
result, and an early opportunity to take corrective action.
For the period February 2012 to January 2013 we had the third lowest HSMR of our peer group of
hospitals against which we benchmark data. In this period our HSMR was 95.9. The best performing
Trust had a rate of 79.8 and the poorest performer had a rate of 104.0.
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Average length of stay
Monitoring the average length of stay for our patients is important in helping patients know how long
they may be in hospital and for the Trust to determine requirements in terms of the number of beds
needed and the requirements of differing specialties. Reports on average length of stay are monitored in
regular Board reports and at a lower level by each Directorate. It is usual to see a higher length of stay
over the winter months from November to March during which period we open additional beds in a
‘winter ward’ to manage the increased demand especially among older patients.
Days
The average length of stay for all patients discharged from the hospital (excluding day cases) in 2012-13
was 3.7 days, as indicated in the flowing graph.
There is a difference in length of stay between elective (planned) admissions and patients that present
as emergencies. The following graph shows that in 2012-13, for all cases, the length of stay for patients
admitted as elective cases was lower than that of emergencies. We would expect this as most elective
cases have very predictable length of stay whereas emergency cases are often more complex and need
longer to treat. The average length of stay for elective admissions was 2.6 days compared to 3.9 days
for emergency patients.
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Days
Patient Safety
Data source: Inpatient Service Department
Days
Among the emergency patient group, the average length of stay for medical patients was 5.3 days and
4.6 days for surgical patients, as shown in the following graph. The Trust uses length of stay as well as
admission and discharge information to predict its workload on a daily basis.
30 day Readmissions
The readmission rate for patients is an important marker in ensuring patients are safely discharge and
that readmissions for the same condition are minimised. In 2012-13 the unplanned 30 day readmission
rate was 5.9%. The following graph shows several months of the most recent data suggesting the 30
day unplanned readmission rate has deteriorated. As stated elsewhere in this report, there will be a
focus in 2013-14 on understanding readmissions to enable us to identify ways to reduce the numbers
appropriately.
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Note: there is a known data quality issue being addressed which will overstate the true level of
admissions.
Patient Experience
Patient Experience Surveys
Listening to patients views and actively seeking feedback is essential to patient-centred care. Taunton
and Somerset NHS Foundation Trust has a ‘multi-layered’ feedback strategy. This is supported by a
patient-centred culture and the values of the hospital. The principles that underpin the strategy are;







Measurement should be continuous and the results available real time.
All patients should have the opportunity to give feedback
Feedback from relatives and carers is encouraged.
Accessible to all, patients will have choice on how they feedback, with a wide range of methods
and support available for patients and families to give feedback.
Feedback and measurement of experience is core business and a standard part of service
delivery
Feedback is used for improvement and is a core element of the Improvement Network.
The equal value of quantitative and qualitative feedback
Specialty/Ward/Department feedback
This is feedback gained by our teams about the service they provide. Giving teams the tools and support
to gain feedback and drive service improvements through the eyes of patients. The Improvement Network
has developed a tool kit to support this, examples of approaches include patient shadowing, patient
stories, surveys (a variety of methods such as telephone, paper surveys, face to face interviewing, apps,
and web/intranet online feedback), feedback cards and focus groups.
Trust wide rolling programme of real time survey feedback
This includes all of the hospital with surveys covering a representative and meaningful sample size.
These are more in depth surveys asking for feedback on what are known to matter most to patients.
These areas broadly relate to consistency and coordination of care, respect and dignity, involvement,
staff, cleanliness and environment, food and pain control. These surveys are available in a number of
formats, volunteer supported interviews, electronic survey’s whilst in the hospital and internet accessible
surveys.
Friends and Family Test
From April 2013 all adult in-patients and patients attending Accident and Emergency will have the
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opportunity to give us feedback on how likely they are to recommend Musgrove to friends and family.
From October 2013 this will include maternity with further roll out in line with national guidance. A range of
methods will be available to allow patients to take up this opportunity at the point of discharge. In January
2013 we introduced the nationally-approved wording by asking patients if they would be likely to
recommend the hospital to family and friends. The results were 73.5% of patients said they were
extremely likely to recommend the hospital to friends or family with 94.4% of patients either extremely
likely or likely to recommend the hospital. Participation in National surveys
As a hospital we participate in national surveys (In-Patient, Out-Patient, A&E, Maternity, and Cancer).
These surveys give us the opportunity to benchmark and particularly the national in-patient survey is
aligned to the CQUIN.
The results of the national inpatient survey 2012 were published in April 2013. For 23 aspects of care we
are significantly better than the average results when compared to 73 Trusts nationwide. These areas
included:








Admission organization and getting to a bed
Hospital food;
Important aspects of care such as involvement and emotional support;
Privacy;
Getting clear information from doctors and nurses
Sufficient nurses on duty;
Discharge focused questions relating to involvement and information; and
Overall rating of care and recommendation of hospital.
How was it for you – Complaints Feedback
Learning from complaints and concerns provides really important feedback. Every complaint and concern
is looked at the see what we can learn and improve as a result.
Since 2011 we have been working in partnership with the Patients Association. Everyone who has made
a formal complaint is sent a survey to ask them about their experience of raising a complaint in our
hospital. The Patients Association provides a level of independence supporting people to tell us what they
think.
Patient and Public Involvement (PPI)
The hospital has a patient Experience Committee which is chaired by a patient. This group has
membership from the local HealthWatch and the CCG. The annual programme of work for patient
experience includes working with key partners and local groups such as the Taunton Deaf Club and
Compass Disability. We also involve and seek feedback via our trust membership which as at January
2013 there are 10,851 public and 3,412 staff members.
The Hospital has a growing number of active volunteers who contribute hugely to the hospital. Our survey
volunteers and Musgrove Partners particularly help us with implementing our PPI and patient feedback
work. Musgrove Partners help with our recruitment and selection of staff, are members of key committees
across the hospital, facilitate focus groups to name only a few of their activities. The Trust Governors
Patient Care Group reviews feedback from patients/relatives and adds to that a regular report from the
Governors on feedback they have gained from the local community called “It’s Good to Know”.
Letters/Comments on national feedback sites
The hospital receives a huge number of thank you letters and comments which are made on the Hospital
internet or via e-mail. Each of these comments is reviewed, forwarded to the appropriate teams / clinical
areas for action as appropriate and responded to. Comments are also made via national on-line services
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such as NHS Choices and Patient Opinion, from February the PALs team will include the review and
response to these in their responsibilities.
Privacy and Dignity
Our patients rightly expect that during their stay in hospital they are treated with dignity and respect. This
is a question that we specifically ask our in our monthly survey of inpatients. We aim for 95% of those
surveyed to feel that they have been treated with dignity and respect.
Percentage (and number) of patients surveyed
who feel they are treated with dignity and respect
2009-10
2010-11
2011-12
2012-13
(1,602)
(1,499)
(1,846)
(1,798)
Always
88%
93%
89%
93%
Most of the time
10%
6%
9%
6%
No
2%
0%
2%
1%
One important aspect is the provision of single sex accommodation, and not having to share sleeping or
washing areas with patients of the opposite sex. This should only happen when it is clinically necessary –
for example, when patients need specialist equipment in critical care or high dependency areas. The
situation is continually monitored and reported to the Trust Board in the Quality Report.
Results from the National Inpatient Survey taken from patients in hospital during July and August
identified that we were worse than average regarding sharing of sleeping areas and bathrooms compared
with other hospitals. Our inpatient survey from July and August 2012 also showed patients from 8 wards
reporting an increase in people reporting some sharing although there were no actual mixes of patients
within sleeping areas at the time. All our wards are compliant with the environmental requirements and we
monitor the situation weekly to ensure any mixing of sexes in sleeping accommodation is for clinically
justified reasons only.
As our local population will know, work has started on the Jubilee Building which will replace five of our
old surgical wards with 112 single en-suite rooms. We look forward to welcoming our first patient there
towards the end of the year.
Patient Care Rounds
Patient care rounds have not be reported before as they form a change to the way care has been
conducted beginning in 2011.
Routinely and regularly attending to patients is an important part of nursing care. The introduction of twohourly formal ‘rounding’ with the intention to provide specific aspects of care was successfully tested in
the Medical Assessment Unit in 2011 and completed as a roll out across all the hospital wards by July
2012. Implementation was supported by staff training and a simple means of documenting care given and
a measurement strategy to enable us to identify if improvements are made.
One important outcome of regular care-rounding should be that call bells are answered promptly. Patients
are asked about this in our monthly survey. The following graph shows improvement overall from 64%
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towards 80% with sustained improvement from October 2012 to February 2013. The dip seen in March
corresponds with an extraordinary rise in the number of emergency admissions when several additional
ward areas were opened to manage the demand that created challenges to the numbers and deployment
of permanent and temporary staff.
Percentage of patients who report that they usually receive help right away/within 1-2 minutes after using call button
(All who had used the call button)
100.0%
80.0%
60.0%
40.0%
April 2012
May 2012
June 2012
July 2012
August
2012
September
2012
October
2012
November
2012
December
2012
January
2013
February
2013
March
2013
Data Source: Monthly Inpatient Survey
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NATIONAL TARGETS AND REGULATORY REQUIRMENTS
Key Targets
Threshold
2008/09 2009/10 2010/11 2011/12 2012/13
Cancer: Decision to Treat in
31 Days
96%
-
96.9%
99.6%
99.4%
98.4%
Maximum waiting time of 31
days
for
subsequent
treatments where subsequent
treatment is surgery
94%
-
95.3%
99.7%
97.1%
96.7%
days
for
subsequent
treatments where subsequent
treatment is Drugs
98%
-
99.0%
100%
100%
99.9%
days
for
subsequent
treatment where subsequent
treatment is Radiotherapy
94%
-
-
100%
100%
98.5%
Cancer:
Referral
to
Treatment in 62 Days.
Measured for all cancers
from date referral is made to
Trust to the date of the first
definitive treatment *
85%
-
91.7%
94.7%
90.7%
88.6%
Maximum two month wait
referral
from
an
NHS
Screening
service
to
treatment for all cancers
90%
-
93.4%
98.8%
100%
95.2%
1
8
3
1
1
0
100%
-
100%
100%
88.8%
89.9%
44
55
48
73
37
19
90%
92%
87.8%
91.5%
91.8%
92.2%
95%
99%
97.6%
97.1%
97.25%
96.5%
92%
-
-
-
-
93.3%
MRSA
Screening of all elective
inpatients for MRSA (ratio of
swabs)
C Difficile
reduction
year on year
18
Week
Referral
to
Treatment: Admitted Patients
18
Week
Treatment:
Patients
Referral
to
Non-Admitted
Maximum time of 18 weeks
from point of referral to
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Key Targets
Threshold
2008/09 2009/10 2010/11 2011/12 2012/13
treatment in aggregate –
patients on an incomplete
pathway
Sexual Health: Access to GU
Clinic (48 hours)
100%
100%
100%
100%
100%
100%
A&E Waiting Times: 4 hours
to admission, transfer or
discharge
98%
98.3%
98.4%
97.1%
95.5%
96.34%
Cancelled Operation: Offered
another binding date within
28 days
95%
99%
93.6%
93.5%
99.1%
98.8%
Maximum Waiting Times:
Revascularisation (No. >3
months)
0
0
0
0
0
0
93%
-
96.5%
96%
94.8%
94.9%
Cancer: Referral to first
appointment (14 days) –
Symptomatic
Breast
Referrals – From January
2010
93%
-
98%
98.8%
96.7%
Maximum Waiting Times:
Rapid Access Chest Pain
Clinics (14 days)
100%
100%
100%
99.6%
100%
100%
Delayed Transfers of Care –
maximum level
3.5%
1.4%
3.2%
4.9%
3.7%
2.6%
% Stroke patients spending
90% or more of their time on
a Stroke Unit
80%
75.7%
41.8%
68%
83%
85%
% High Risk TIA patients
treated in 24 hours
60%
-
23%
59%
80%
76%
Cancer: Referral to
appointment (14 days)
first
95.8%
Q4 only
*62 day cancer wait: the indicator is expressed as a percentage of patients receiving their first definitive
treatment for cancer within 62 days of an urgent GP referral for suspected cancer. An urgent GP referral is
one which has a two week wait from the date that the referral is received to first being seen by a consultant.
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Annex One
A draft copy of our Quality Account was sent to:
 Somerset NHS Clinical Commissioning Group
 Bristol Healthwatch
 Oversight and Scrutiny Committee, Somerset County Council
The following responses were received:
Clinical Commissioning Group report
As lead commissioner, Somerset Clinical Commissioning Group (and previously NHS Somerset)
has monitored the safety, effectiveness and patient experience of health services at Taunton and
Somerset NHS Foundation Trust during 2012/13. The Trust’s engagement in the quality contract
monitoring process provides the basis for commissioners to comment on the quality account
including performance against quality improvement priorities and the quality of the data included.
We have reviewed the achievements against the National Performance Indicators as outlined in
the account and can confirm that the reported position is accurate.
We have reviewed the identified Quality Improvement priorities for inclusion in the Quality
Accounts for 2012 /13 and would comment as follows:
Quality - The Patient at the Heart of Everything We Do
Ensuring that we put patients first in all that we do is essential for patients to receive care that
meets their needs, and is provided by caring and compassionate staff. The publication of the
Francis report has emphasised that the NHS must put patients at the centre and ensure that
fundamental standards of care are met. The CCG acknowledges the strong ethos within the Trust
for stakeholder and patient engagement and recognises the work the Trust has undertaken to
strengthen arrangements for improved patient experience through the use of real time patient
surveys, improved experience for people with a learning disability and focus on the needs of
people with dementia and the environment of care. The CCG can confirm that the Trust regularly
reviews the quality and safety of its services using a variety of quality indicators and these are
reported to the CCG at the quarterly clinical quality review meetings.
Patient Safety

Somerset CCG confirms the data for healthcare acquired infections for 2012 /13 as correct. The
Trust achieved the national target of no more than 44 cases of C difficile acquired after 72 hours
of admission, with an overall year end position of 19 cases. This is a considerable achievement
and the Trust is commended for the focus given to the reduction of cases. The Trust is also
commended for achieving the national target of no more than one case of MRSA bloodstream
infection, with no cases reported during the year. Somerset CCG notes evidence of continued
focus on reducing healthcare associated infections which includes a focus on reduction of surgical
site infections and catheter associated urinary tract infections, as well as learning from outbreaks
and incidents to improve care for patients.

Improving patient safety by reducing falls and pressure ulcers.
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The Trust has implemented a wide range of interventions to reduce and mitigate the risk of
patients falling in line with local targets. The CCG confirms the achievement of the Trust in both
the reducing the rate of falls to patients and falls that cause harm and the assurance provided by
monthly reporting on use of the falls care bundle Considerable focus has been given to reducing
the number of patients falling, as well as those falls which result in harm. This area of patient
safety will continue to be subject to ongoing scrutiny via the Clinical Quality Review process to
ensure that the Trust continues to focus on reducing the number of patients who fall and who are
harmed as a result of falls.
It is pleasing to see the improvements achieved and the actions required to improve practice
included in the report resulting from serious untoward incidents. Ensuring lessons are learned
from serious untoward incidents, and that these are embedded across the Trust, provides
evidence of a strong safety culture and focus on improvement.
The increase in rate of reported pressure ulcers (grade 2 or above) from 1.14 per 1000 bed days
in 11/12 to 1.33 per 1000 bed days in 12/13 is acknowledged. Somerset CCG confirms the
position that, whilst improvements have been made in identifying, reporting and investigating
hospital acquired pressure ulcers, the reduction target was not met. The Trust has participated as
a member of the Somerset Harm Free Care Collaborative to develop a consistent approach to
reducing pressure ulcers through use evidenced based tools.
In recognition of the need for improved focus and reduction of incidence, work in the Trust will
continue to reduce pressure ulcer development in patients in receipt of healthcare services and to
achieve a zero tolerance culture to the development of pressure ulcers. The Trust has been set a
challenging target of 40% reduction in avoidable hospital acquired cases for 13/14 in light of this
position.

Somerset CCG notes the improvements made during 2012/13 from the Trust’s local inpatient
survey data reporting help and assistance for patients with feeding. The CCG endorses the
Trust’s intention to continue with a focus on ensuring patients receive an appropriate level of
hydration and nutrition and will continue to monitor performance against this area during the
coming year.

Caring for Patients with dementia
The Trust has gained significant momentum with improvements in the early identification and
diagnosis of patients with dementia and has demonstrated achievement of Level 2 standards of
the South West Dementia Partnership Strategy in accordance with local CQUIN requirements.
Whilst the target of 90% was not achieved by year end to support early diagnosis, the Trust has
demonstrated the greatest distance of travel against these indicators than comparators from
across the South West region.
Never Events
The Trust reported one Never Event of wrong site surgery that involved the services of another
NHS provider. The Trust instigated the ‘Being Open’ policy with the patient concerned and the
final investigation report has been shared with the patient so that they could both contribute and
understand the changes made to ensure that this did not happen again. A key area of work going
forward was to improve arrangements for the timeliness of specimen and test results to be
available to multi-disciplinary teams for review and to ensure that all staff receive induction into
their role including locum staff. The process of investigation and review with both organisations
involved, allowed for organisational learning and improvements in the management of the patient
pathway to reduce the likelihood of a similar occurrence.
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Serious Incidents requiring Investigation (SIRIs)
The Trust reports all SIRIs requiring investigation to Somerset CCG and the progress of the
investigation and the implementation of the lessons learned is monitored by the CCG. During
2012 – 13 the termination of pregnancy service provided by the Trust was inspected by the Care
Quality Commission and found to be non-compliant with ensuring two doctors signed the consent
form for patients requiring a termination. The Trust undertook a robust investigation which
indicated that the pathway and approach in place was designed around meeting the needs of the
patients. The Trust has fully implemented the recommendations of the investigation and ensured
that the pathway is now compliant.
Clinical Effectiveness

The Trust embarked on a local programme of improvement in communication systems including
Complaints and PALS and issue of discharge summaries. A reduction in the number of formal
complaints is noted across the year, although an increase in Quarter 3 was noted and discussed
via Clinical Quality Review meetings.
A local programme of improvement for Administration Excellence was launched during the year
and changes to processes, including the development of standard operating procedures, to
ensure consistency across the Trust, have been presented to the CCG as evidence of
improvements.

Clinical audit programme
The Trust has participated in a broad number of national audit programmes which provide
assurance of the quality of treatment and care, and the outcomes of care for patients. It is positive
to see the actions being taken in response to the outcomes of participation in national audits and,
in particular, the actions taken for cancer care.
The Trust’s achievement of a consistently low HSMR across a seven day week continues to
reflect the impact of introducing consultant working at weekends and increased availability of the
Critical Care Outreach Team and should be noted as evidence of good practice.
Patient Experience
Somerset CCG notes the improvements made during 2012 –13 in the timeliness of the provision
of written discharge summaries to GPs and the number of patients who receive copies of letters
sent by hospital doctors to GPs. The CCG will continue to monitor these areas and is working with
the Trust to audit the quality of discharge summaries in 2013 – 14. Communication about the care
and treatment for patients in hospital and provision of information to relatives is important in
ensuring both the continuity of care for patients as well as safe treatment.
The performance of the Trust in the annual patient survey for 2012 – 13 indicates that in general
the performance of the Trust compares well to other Trusts and to previous year’s performance.
A number of patients were concerned about sharing bathrooms with patients of the opposite sex.
On further investigation this relates to wards where there is only one assisted bathroom but there
are single sex showers and to clinical areas where patients receive one to one care at times when
they need close observation. Areas where the Trust did not perform so well include noise at
night, being told about side effects from medicines and danger signals to watch for after going
home. These will be areas for focus in 2013 – 14.
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Improvements in the provision of clinical correspondence for patients and the administrative
systems during the year has been a key focus for the Trust and the CCG has monitored the
reduction in the number of PALS enquiries and complaints in this area.
The CCG confirms the proportion of staff reporting in the annual staff survey that they would
recommend the hospital to their friends and family was 74%. This provides a measure of the
confidence of the staff in the care provided in the hospital. The Trust is well placed to start
reporting against the Friends and Family Test in 2013 and to publish these results for patients and
the public to review the recommendations from people using the services at Musgrove Park.
Data Quality
The Trust has continued to make progress in improving data quality. It is important for the Trust to
demonstrate the quality of care provided and for this to be benchmarked against other NHS
providers. With increasing patient choice the provision of high quality data on the effectiveness
and safety of the care provided to patients at Musgrove Park Hospital will be important for
patients who choose to have their treatment at the hospital.
Quality Improvement Priorities for 2013/14
Somerset CCG supports the quality improvement priorities identified by the Trust for the coming
year. In the light of the publication of the Francis report and the continued focus of the Trust on
both reducing harm from healthcare to patients, improving the experience of patients of
healthcare and ensuring that older people with dementia receive care from staff who have the
skills and expertise to care for this vulnerable group of patients is important.
A number of these priorities have been included in the Commissioning Quality and Innovation
(CQUIN) framework that we have agreed with the Trust as set out below:
 Risk assessment and prophylaxis for VTE (blood clots)
 Friends and Family Test
 Use of the Patient Safety Thermometer
 Identification and early diagnosis of dementia
 Improvement in End of Life care
 Administration of antibiotics in neutropenia
 Provision of test results following outpatient appointments
 Improvement in the management of diabetes foot care
 Development of a Frail Elderly Care pathway
 Reduction in incidence of hospital acquired pressure ulcers.
We can confirm that the Quality Account meets national requirements in respect of content,
provides a balanced view of the Trusts’ achievements and as such is an accurate reflection of the
quality of services provided. Taunton and Somerset has made significant achievements in
improving the quality of the services provided during 2013 – 14 and the number of national
awards for safe care is additional assurance of this position.
We look forward to continuing to work with Taunton and Somerset NHS Foundation Trust during
2013/14 to improve the safety, clinical effectiveness and patient experience of the services
provided by the Trust.
Please contact me at the above address if you wish to discuss any of the above comments
further.
Yours sincerely
Lucy Watson, Director of Quality and Patient Safety
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Healthwatch Report
“Statement written by Healthwatch on behalf of Somerset Local Involvement Network disbanded
31st March 2013.
Somerset LINk welcomed the opportunity to contribute to the Quality Report prepared by Taunton
and Somerset NHS Foundation Trust. The LINk had a positive and constructive working
relationship with the Trust and with the lead on Quality Accounts at Taunton and Somerset NHS
Foundation Trust and recommended that this relationship is continued.
They recommended that Healthwatch responds to the NHS Quality Accounts (QA) and where
necessary applies pressure to ensure that Quality Account documents are received in good
enough time for Healthwatch to develop a thorough response and that information relevant to the
QA is available, discussed and consulted on with Healthwatch throughout the year.
Healthwatch Somerset began in April 2013, and they are not in a position to provide a
comprehensive response to this year’s Quality Account. They look forward to submitting a
comprehensive response in 2014.”
~~~~~
SCC Oversight and Scrutiny Committee
“Thank you for sending us the Trust’s 2012/13 Quality Report, for comment.
Since the last Quality Report there has, of course, been the Francis Report and we noted in the
local press that TSFT had promptly reacted and commented on its level of its compliance with the
core underlying themes of his recommendations – ‘a structure of clearly understood fundamental
standards’, ‘openness, transparency and candour throughout the system’, ‘compassionate caring
and committed nursing’, ‘strong and patient-centred healthcare leadership’ and ‘accurate, useful
and relevant information’. We continue to recognise that the Trust’s commitment to ‘putting
patients at the heart of everything we do’ suggests we are fortunate in Somerset to have our
largest acute hospital already firmly committed to delivering on the Francis principles. We are also
confident that the Trust has the processes and procedures – and, moreover, the right ethos
shared by its management and staff – to make progress in the small number of areas where it
recognises more can still be done. We look forward to receiving an update from the Trust,
perhaps in early 2014, a year post Francis, on what changes it has made to further improve the
service it provides to Somerset’s residents in compliance with the Report’s recommendations and
in its aspirations for overall NHS service delivery.
As a Scrutiny Committee, we have recommended to the incoming administration that the loss of
the previous Health Scrutiny over the past four years should be addressed. We are confident that,
whichever party takes control next month, this will be actioned, particularly in light of the
authority’s having taken on new Health & Wellbeing powers since the start of this month.
As we looked at your Quality Report from a resident’s perspective, we would make only two
further comments; firstly we would like to congratulate the Trust on the work it has done to reduce
the incidence of the two dominant hospital-acquired infections, MRSA and c.diff, delivering a far
better performance than in many other parts of the country. And secondly – as you have asked for
our suggestions – we would ask you to look further into patient communications. Major retailers
suggest that, as a rule of thumb, for every customer who complains about something there are
probably another 10 who felt moved to complain, but never quite got round to it. Poor patient
communications – mostly relating to appointments and associated communication delays – often
comes up in councillor/resident contacts as an issue and it is a shame to see the perception of the
Trust’s excellent clinical performance occasionally marred by this aspect.
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Finally, we look forward to further, closer, working with the Trust in the coming year. We know we
can rely on your continuing focus on the primacy of patients and their needs.
April 30th 2013”
~~~~~
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Annex Two
Statement of Directors’ Responsibilities in Respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health Service Quality
Accounts Regulations 2010 to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual
quality reports (which incorporate the above legal requirements), and on the arrangements that
foundation trust boards should put in place to support the data quality for the preparation of the
quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

The content of the Quality Report meets the requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2012-13.

The content of the Quality Report is not inconsistent with internal and external sources of
information including:
-
Board minutes and papers for the period April 2012 to June 2013;
-
Papers relating to Quality reported to the Board over the period April 2012 to June
2013;
-
Feedback from the commissioners dated 15.05.2013;
-
Feedback from governors dated 07.03.2013;
-
Feedback from Local Healthwatch organisations 17.05.13;
-
Feedback from Somerset County Council 30.3. 2013;
-
The Trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS complaints Regulations 2009 (as part of the Trust’s
Governance Schedule, this report will be reviewed at Trust Board in October 2013);
-
The 2012 national patient survey report 16.04.2013;
-
The 2012 national staff survey report 11.03. 2013;
-
The Head of Internal Audit’s annual opinion over the trust’s control environment
dated 18.04.2013;
-
Care Quality Commission (CQC) Quality and Risk Profiles dated 31.03.2013.

The Quality Report presents a balanced picture of the Taunton and Somerset NHS
Foundation Trust’s performance over the period covered.

The performance information reported in the Quality Report is reliable and accurate.

There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm they are working effectively in practice.
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
Patient Experience
The data underpinning the measures of performance reported in the Quality Report is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review, and the Quality Report has been
prepared in accordance with Monitor’s annual reporting guidance (which incorporates the
Quality
Accounts
regulations),
(published
at
www.monitornhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality
for the preparation of the Quality Report (available at www.monitornhsft.gov.uk/annualreportingmanual).
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
NB: sign and date in any colour ink except black
29 05 13
Date…………………………………………….Chairman
29 05 13
Date…………………………………………… Chief Executive
154
Patient Safety
Patient Experience
Annex Three
Independent Auditor’s Report to the Board of Governors of Taunton and
Somerset NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Taunton and Somerset NHS Foundation
Trust to perform an independent assurance engagement in respect of Taunton and Somerset
NHS Foundation Trust’s Quality Report for the year ended 31 March 2013 (the ‘Quality Report’)
and specified performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2013 in the Quality Report that have been subject to
limited assurance consist of the following national priority indicators as mandated by Monitor:
1. Number of Clostridium difficile infections; and
2. Maximum cancer waiting time of 62 days from urgent GP referral to first treatment for all
cancer.
We refer to these national priority indicators collectively as the “specified indicators”.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in
accordance with the assessment criteria referred to in on page 153 (Annex 2) of the Quality
Report (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”) 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;
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.
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:





Board minutes for the period April 2012 to the date of signing this limited assurance report
(the period);
Papers relating to Quality reported to the Board over the period April 2012 to the date of
signing this limited assurance report;
Feedback from the Commissioners, Somerset Clinical Commissioning Group, dated
15.05.2013;
Feedback from Governors dated 07.03.2013;
Feedback from local Healthwatch organisations, Bristol Healthwatch, 17.05.2013;
155
Patient Safety






Patient Experience
The trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009;
Feedback from other stakeholders involved in the sign-off of the Quality Report, Somerset
County Council 30.3. 2013;
The 2012 national patient survey dated 16.04.2013;
The 2012 national staff survey dated 11.03. 2013;
Care Quality Commission quality and risk profiles dated 31.03.2013; and
The Head of Internal Audit’s annual opinion over the trust’s control environment dated
18.04.2013.
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
Taunton and Somerset NHS Foundation Trust as a body, to assist the Council of Governors in
reporting Taunton and Somerset 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 2013, 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 Taunton and
Somerset 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:



Evaluating the design and implementation of the key processes and controls for
managing and reporting the indicators
Making enquiries of management
Analytical procedures

Limited testing, on a selective basis, of the data used to calculate the specified indicators
back to supporting documentation.

Comparing the content requirements of the FT ARM to the categories reported in the
Quality Report.

Reading the documents.
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.
156
Patient Safety
Patient Experience
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
Directors’ interpretation of the Criteria in Annex 2 of the Quality Report.
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 nonmandated indicators in the Quality Report, which have been determined locally by Taunton and
Somerset 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 2013,
 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;
 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.
PricewaterhouseCoopers LLP
Chartered Accountants
Plymouth
29 May 2013
The maintenance and integrity of the Taunton and Somerset’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.
157
158
11.
ANNUAL ACCOUNTS
Taunton & Somerset NHS Foundation Trust Accounts for the Year Ended 31 March 2013 Taunton and Somerset NHS Foundation Trust - Annual Report and Accounts 2012/13
159
TAUNTON AND SOMERSET NHS FOUNDATION TRUST
ACCOUNTS FOR THE YEAR ENDED
31 MARCH 2013
PRESENTED TO PARLIAMENT PURSUANT TO SCHEDULE 7,
PARAGRAPH 25 (4) (a) OF THE NATIONAL HEALTH SERVICE
ACT 2006.
Taunton and Somerset NHS Foundation Trust
Annual Accounts for the Financial Year ended 31 March 2013
INDEX
Page
FOREWORD TO THE ACCOUNTS
2
INDEPENDENT AUDITORS' REPORT TO THE BOARD OF GOVERNORS
3-4
STATEMENT OF COMPREHENSIVE INCOME
5
STATEMENT OF FINANCIAL POSITION
6
STATEMENT OF CHANGES IN TAXPAYERS' EQUITY
7
STATEMENT OF CASH FLOWS
8
NOTES TO THE ACCOUNTS
10-41
Page 1
Taunton and Somerset NHS Foundation Trust - Annual Accounts 2012/13
FOREWORD TO THE ACCOUNTS
These accounts for the financial year ended 31 March 2013 have been prepared by Taunton and Somerset
NHS Foundation Trust in accordance with paragraphs 24 and 25 of Schedule 7 to the National Health
Service Act 2006 in the form in which Monitor, the Independent Regulator of NHS Foundation Trusts, with
the approval of the Treasury, has directed.
The Taunton and Somerset NHS Foundation Trust annual report and accounts are presented to Parliament
pursuant to schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006.
Signed…………………………………………………………………
Jo Cubbon
Chief Executive
Date: 29 May 2013
Page 2
Independent Auditors’ Report to the Council Of Governors of Taunton and Somerset
NHS Foundation Trust
We have audited the financial statements of Taunton and Somerset NHS Foundation Trust for
the year ended 31 March 2013 which comprise the Statement of Comprehensive Income, the
Statement of Financial Position, the Statement of Cash Flows, the Statement of Changes in
Taxpayers’ Equity and the related notes. The financial reporting framework that has been
applied in their preparation is the NHS Foundation Trust Annual Reporting Manual 2012/13
issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
Respective responsibilities of directors and auditors
As explained more fully in the Chief Executive’s Statement of responsibilities as the
Accounting Officer of Taunton & Somerset NHS Foundation Trust set out on page 66 of the
Annual Report 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 2012/13. 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 International
Standards on Auditing (ISAs) (UK and 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 Taunton & Somerset 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.
Scope of the audit of the financial statements
An audit involves obtaining evidence about the amounts and disclosures in the financial
statements sufficient to give reasonable assurance that the financial statements are free from
material misstatement, whether caused by fraud or error. This includes an assessment of:
whether the accounting policies are appropriate to the NHS Foundation Trust’s circumstances
and have been consistently applied and adequately disclosed; the reasonableness of
significant accounting estimates made by the NHS Foundation Trust; 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. If we become aware of any apparent material misstatements or
inconsistencies we consider the implications for our report.
Opinion on financial statements
In our opinion the financial statements:

give a true and fair view, of the state of the NHS Foundation Trust’s affairs as at 31
March 2013 and of its income and expenditure and cash flows for the year then
ended to 31 March 2013; and

have been prepared in accordance with the NHS Foundation Trusts Annual Reporting
Manual 2012/13.
Opinion on other matters prescribed by the Audit Code for NHS Foundation Trusts
In our opinion

the part of the Directors’ Remuneration Report to be audited has been properly
prepared in accordance with the NHS Foundation Trusts Annual Reporting Manual
2012/13; and
Page 3

the information given in the Directors’ Report for the financial year for which the
financial statements are prepared is consistent with the financial statements.
Matters on which we are required to report by exception
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
2012/13 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.
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.
Heather Ancient (Senior Statutory Auditor)
For and on behalf of PricewaterhouseCoopers LLP
Chartered Accountants and Statutory Auditors
Plymouth
29 May 2013
a) The maintenance and integrity of the Taunton & Somerset 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.
Page 4
Taunton and Somerset NHS Foundation Trust Annual Accounts 2012/13
STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED
31 MARCH 2013
Note
2012/13
£000
2011/12
Restated
£000
Income from activities
3
225,701
217,432
Other operating income
4
30,621
27,195
Operating expenses
5
(250,597)
(238,125)
5,725
6,502
313
(1,605)
(3,862)
321
(1,352)
(3,962)
(5,154)
(4,993)
(100)
0
0
0
471
1,509
0
0
471
1,509
Revaluation gains and impairment losses on property, plant and
equipment
(1,744)
3,553
Total Other Comprehensive Income
(1,744)
3,553
TOTAL COMPREHENSIVE INCOME FOR THE YEAR
(1,273)
5,062
Operating surplus
Finance costs
Finance income
Finance expense - financial liabilities
PDC dividends payable
8
9
Net finance costs
Share of loss of Joint ventures accounted for using the equity
method
Corporation tax expense
Surplus from continuing operations
Surplus/ (deficit) of discontinued operations and the gain/(loss) on
disposal of discontinued operations
SURPLUS FOR THE YEAR
29
Other comprehensive income:
The 2011/12 other operating income and expenditure has been restated for the grossing up of an agency
agreement to ensure consistency with the 2012/13 accounts as defined in the accounting policy.
The notes on pages 10 to 41 form part of these accounts.
Page 5
STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2013
Note
31 MARCH 2013
31 MARCH 2012
£000
£000
536
156,247
605
143,356
NON-CURRENT ASSETS:
Intangible assets
Property, plant and equipment
11.1
12
Investments in joint ventures
Trade and other receivables
16.1
Total non-current assets
CURRENT ASSETS:
Inventories
Cash and cash equivalents
15
16.1
20
Total current assets
(100)
0
0
284
156,683
144,245
2,743
9,843
34,538
2,850
10,236
29,604
47,124
42,690
CURRENT LIABILITIES:
Trade and other payables
17.1
(19,359)
(16,934)
Borrowings
17.3
(1,168)
(966)
Provisions
19
(356)
(356)
(1,655)
(1,572)
Total current liabilities
(22,538)
(19,828)
Total assets less current liabilities
181,269
167,107
Other liabilities
17.2
NON-CURRENT LIABILITIES:
17.1
(82)
(83)
Borrowings
17.3
(31,825)
(16,771)
Provisions
19
(801)
(761)
(4,529)
(4,787)
Total non-current liabilities
(37,237)
(22,402)
TOTAL ASSETS EMPLOYED
144,032
144,705
76,971
76,371
Other liabilities
17.2
TAXPAYERS' EQUITY:
Public dividend capital
Revaluation reserve
29,645
31,954
Income and expenditure reserve
37,416
36,380
TOTAL TAXPAYERS' EQUITY
144,032
144,705
The financial statements on pages 5 to 41 were approved by the Board on 29 May 2013 and signed on
its behalf by
Signed…………………………………………………………………
Jo Cubbon
Chief Executive
Date: 29 May 2013
Page 6
STATEMENT OF CHANGES IN TAXPAYERS' EQUITY YEAR ENDED 31 MARCH 2013
Public
Revaluation Income and
Dividend
reserve
expenditure
Capital
reserve
(PDC)
£000
£000
£000
Total
£000
76,371
31,954
36,380
144,705
Surplus for the year
0
0
471
471
Revaluation gains and impairment losses on property, plant
and equipment (note 13.1)
0
(1,744)
0
(1,744)
Total comprehensive income for the period
0
(1,744)
471
(1,273)
0
(524)
524
0
0
600
(41)
0
41
0
0
600
76,971
29,645
37,416
144,032
Taxpayers' Equity at 1 April 2012
Transfer of the excess of current cost depreciation over
historical cost depreciation to the income and expenditure
reserve
Transfer to retained earnings on disposal of assets
Public Dividend Capital received
Taxpayers' Equity at 31 March 2013
STATEMENT OF CHANGES IN TAXPAYERS' EQUITY YEAR ENDED 31 MARCH 2012
Public
Dividend
Capital
(PDC)
Revaluation Income and
reserve
expenditure
reserve
Total
£000
£000
£000
£000
76,360
29,921
33,351
139,632
Surplus for the year
0
0
1,509
1,509
Revaluation gains and impairment losses on property, plant
and equipment (note 13.1)
0
3,553
0
3,553
0
3,553
1,509
5,062
Transfer of the excess of current cost depreciation over
historical cost depreciation to the income and expenditure
reserve
0
(1,115)
1,115
0
Other transfers between reserves
0
(405)
405
0
11
0
0
11
76,371
31,954
36,380
144,705
Taxpayers' Equity at 1 April 2011
Total comprehensive income for the period
Taxpayers' Equity at 31 March 2012
Page 7
STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31 MARCH 2013
Note
Cash flows from operating activities
Operating surplus
Non-cash income and expense:
Depreciation and amortisation
Impairments
Reversals of impairments
Amortisation of PFI credit
Decrease in trade and other receivables
Decrease in other assets
Decrease/(Increase) in inventories
Decrease/(increase) in trade and other payables
Decrease in other liabilities
Increase in provisions
Loss on disposal
Other movements in operating cash flows
5.1
5.1
4.1
4.1
16.1
29
15
17.1
17.2
19
Net cash generated from operations
Cash flows from investing activities
Interest received
Purchase of intangible assets
Purchase of property, plant and equipment
Proceeds from sales of property, plant and equipment
8
11
12
Net cash used in investing activities
Cash flows from financing activities
Interest paid
Interest element of finance leases
Interest element of Private Finance Initiative obligations
2011/12
£000
£000
5,725
6,502
8,513
2,893
0
(259)
536
100
107
188
(175)
15
13
462
8,100
670
(188)
(259)
22
0
(236)
(17)
(6)
253
36
(410)
18,118
14,467
313
(102)
(17,983)
393
321
(305)
(4,826)
682
(17,379)
(4,128)
600
11
12,000
0
17.3
17.3
(960)
(703)
(12)
(607)
18.1
18.2
(13)
0
(1,264)
0
(7)
(1,210)
(4,002)
(1,463)
(3,875)
(36)
4,195
(5,736)
Loans received from the Foundation Trust Financing Facility
Capital element of finance lease rental payments
Capital element of Private Finance Initiative obligations
2012/13
PDC Dividends paid
Cash flows used in other finance activities
Net cash used in financing activities
Increase in cash and cash equivalents
20
4,934
4,603
Cash and cash equivalents at beginning of period
20
29,604
25,001
Cash and cash equivalents at end of period
20
34,538
29,604
Page 8
Nature and Purposes of Reserves
Revaluation Reserve
The reserve comprises the sum of all past revaluations of the Trust's non-current assets that have resulted
in increases in the value. The reserve can be used to absorb future revaluations of non-current assets that
result in a fall in value to the extent that a positive reserve exists for individual assets.
Income and Expenditure Reserve
This reserve is an accumulation of all past surpluses and deficits. There are also periodic transfers to the
reserve from the revaluation reserve relating to the disposal of non-current assets and the excess cost of
current depreciation over historic cost depreciation. The reserve is a pool of resource to be used for
investment purposes or to fund potential future deficits.
Page 9
NOTES TO THE ACCOUNTS
Accounting Policies
g q
of the NHS Foundation Trust Annual Reporting Manual which shall be agreed with HM Treasury.
Consequently, the financial statements have been prepared in accordance with the 2012/13 NHS
Foundation Trust Annual Reporting Manual issued by Monitor. The accounting policies contained in
that manual follow International Financial Reporting Standards (IFRS) and HM Treasury's Financial
Reporting Manual to the extent that they are meaningful and appropriate to NHS Foundation Trusts.
The accounting policies have been applied consistently in dealing with items considered material in
relation to the accounts. The preparation of financial statements in conformity with IFRS requires the
use of certain critical accounting estimates and requires management to exercise its judgement to
apply to the Trust's accounting policies (see note 1.19). Accounts have been prepared on a going
concern basis.
Accounting Convention
The accounts have been prepared under the historical cost convention as modified by the revaluation
of preperty, plant and equipment in accordance with EU endorsed International Financial Reporting
Standards and IFRIC interpretations.
1.2 Income Recognition
Income in respect of services provided is recognised when, and to the extent that, performance
occurs and is measured at the fair value of the consideration receivable. The main source of income
for the NHS Foundation Trust is contracts with commissioners in respect of healthcare services.
Where income is received for a specific activity which is to be delivered in the following financial year,
that income is deferred.
Income from the sale of non-current assets is recognised only when all material conditions of sale
have been met, and is measured as the sums due under the sale contract.
The Trust changed the form of it's contracts with NHS commissioners to follow the Department of
Health's payment by results methodology in 2006 resulting in payment at national and local tariff rates
as appropriate.
The Trust has included income relating to partially completed inpatient spells (where a patient has
begun but not completed their treatment at 31 March equivalent to work in progress), this is included
in the accounts is an indicative estimate based on an exercise carried out to identify partially
completed spells as at 31st March 2013. The valuation was calculated by apportioning the tariff to the
spells.
All income and activities are for the provision of health and health related services in the UK.
Other operating income and expenditure is grossed up for an agency service carried out on behalf of
two Strategic Health Authorities. The service provided is a payroll hosting service for the Psychology
students in the south west and south cental areas. The increases the income and staff costs in the
operating expenditure note by £5.8m in 2012/13 (£5.2m in 2011/12). 2011/12 results have been
restated to ensure consistency with this policy.
1.3 Expenditure on employee benefits
Short term employee benefits
Salaries, wages and employment-related payments are recognised in the period in which the service
is received from employees. The cost of annual leave entitlement earned but not taken by employees
at the end of the period is recognised in the financial statements to the extent that employees are
permitted to carry-forward leave into the following period.
Pension costs
Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of
the benefits payable under these provisions can be found on the NHS Pensions website at
www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS
employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in
England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to
identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is
accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in
the scheme is taken as equal to the contributions payable to the scheme for the accounting period. In
order that the defined benefit obligations recognised in the financial statements do not differ materially
from those that would be determined at the reporting date by a formal actuarial valuation, the FREM
requires that "the period between formal valuations shall be four years, with approximate assessments
in intervening years". An outline of these follows:
1.1
Page 10
1.3
Expenditure (continued)
Pension costs
a) Full actuarial (funding) valuation
The purpose of this valuation is to assess the level of liability in respect of the benefits due under the
scheme (taking into account its recent demographic experience), and to recommend the contribution
rates. The last formal 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 have been suspended by HM Treasury on value for money grounds whilst 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. Employer and employee contribution rates are
currently being determined under the new scheme design.
b) Accounting valuation
A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the
reporting period. 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. However, as the interval since the last formal valuation now exceeds four years,
the valuation of the scheme liability as at 31 March 2013, is based on detailed membership data as at
31 March 2013 with summary global member and accounting data. In undertaking this actuarial
assessment, the methodology prescribed in IAS 19, relevant FReM interpretatiions, and the discount
rate prescribed by HM Treasury have also been used. The latest assessment of the liabilities of the
scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension
Scheme (England and Wales) Pension Accounts, published annually. These accounts can be viewed
on the NHS Pensions Website. Copies can also be obtained from the Stationery Office.
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 participants as defined
by the Scheme Regulations have their annual pensions based upon total pensionable earnings over
the relevant pensionable service.
With effect from 1 April 2008 members can choose to give up some of their annual pension for an
additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new
provision is known as "pension commutation".
Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act
1971, and are based on changes in retail prices in the twelve months ending 30 September in the
previous calendar year. From 2011-12 the Consumer Price Index (CPI) will be used to replace the
Retail Prices Index (RPI).
Early payment of a pension, with enhancement, is available to members of the scheme who are
permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of
twice final year's pensionable pay for death in service, and five times their annual pension for death
after retirement is payable.
For early retirements other than those due to ill health the additional pension liabilities are not funded
by the scheme. The full amount of the liability for the additional costs is charged to the employer.
Members can purchase additional service in the NHS scheme and contribute to money purchase
AVC's run by the schemes approved providers or by other Free Standing Additional Voluntary
Contributions (FSAVC) providers.
1.4
Other expenditure on goods and services
Expenditure on goods and services is recognised when, and to the extent that they have been
received, and is measured at the fair value of those goods and services. Expenditure is recognised in
operating expenses except where it results in the creation of a non-current asset such as property,
plant and equipment.
Page 11
1.5
Intangible assets
Recognition
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 services will
potentially be provided to the Trust, and where the cost of the asset can be measured reliably. Where
internally generated assets are held for service potential, this involves a direct contribution to the
delivery of services to the public.
Measurement
Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to
create, produce and prepare the asset to the point that it is capable of operating in the manner intended
by management.
Subsequently intangible assets are measured at fair value. Revaluation gains and losses and
impairments are treated in the same manner as for Property, Plant and Equipment.
Intangible assets held for sale are measured at the lower of their carrying amount or fair value less
costs to sell.
Amortisation and impairment
Intangible assets are amortised on a straight line basis over their expected useful lives which is
consistent with the consumption of economic or service delivery benefits.
The carrying value of intangible assets is reviewed for impairment at the end of the first full year
following acquisition and in other periods if events or changes in circumstances indicate the carrying
value may not be recoverable.
Software
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.
Purchased computer software licences are capitalised as intangible non-current assets where
expenditure of at least £5,000 is incurred and amortised over the shorter of the term of the licence and
their useful lives.
Useful life (years)
Asset category
Software licences
5-7
1.6 Property, Plant and Equipment
Recognition
Property, Plant and Equipment is capitalised where:
(a) it is held for use in delivering services or for administrative purposes;
(b) it is probable that future economic benefits will flow to, or service potential be provided to, the Trust;
(c) it is expected to be used for more than one financial year;
(d) the cost of the item can be measured reliably and;
(e) has an individual cost of at least £5,000; or
(f) the items 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
(g) form part of the initial equipping and setting-up cost of a new building or refurbishment of a ward or
unit, irrespective of their individual or collective cost.
h) where a large asset, for example a building, includes a number of components with significantly
different asset lives, the components are treated as separate assets and depreciated over their own
useful economic lives.
Measurement
Valuation
All property, plant and equipment assets are measured initially at cost, representing the costs directly
attributable to acquiring or constructing the asset and bringing it to the location and condition necessary
for it to be capable of operating in the manner intended by management. All assets are measured
subsequently at fair value. The frequency of the revaluations is dependant on the changes in the fair
value of the items of property, plant and equipment being revalued.
Page 12
1.6
Property, Plant and Equipment (cont)
Property assets
The fair value of land and buildings is determined by valuations carried out by the District Valuers of
the Revenue and Customs Government Department. The valuations are carried out in accordance
with the Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation Manual and are carried
out primarily on the basis of Depreciated Replacement Cost (DRC) which is measured on a Modern
Equivalent Asset basis for specialised operational property. Non specialised operational property is
measured on an Existing Use Value.
The component elements of each property asset are depreciated individually where the value of the
component parts are judged to be material in relation to the overall value of that asset and where the
useful economic lives of the components are significantly different to that of the overall property asset.
The component parts that are individually depreciated by the Trust are building structures, engineering
elements and external works.
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 at open market value.
The District Valuer has supplied amended estimates of the diminution in value relating to operational
buildings scheduled for imminent closure and subsequent demolition, these buildings have been
written down in the accounts to these values. Open market values have also been provided for land
and residences.
Assets under construction are valued at cost and are subsequently revalued by professional valuers if,
when brought into use, factors indicate that the value of the asset differs materially from its carrying
value. Otherwise, the asset should only be re-valued on the next occasion when all assets of that class
are re-valued. Work in progress is assessed at the financial year end on the basis of identified work
completed that has been certified as such by Trust staff or advisors. Payments on account for work not
yet undertaken are accounted for as prepayments.
Non-property assets:
For non-property assets the depreciated historical cost basis has been adopted as a proxy fair value in
respect of assets which have short lives or low values. Where appropriate, assets assessed to be
either high value or long life have been revalued to their current depreciated replacement cost using
estimations of current market value.
Depreciation
Items of Property, Plant and Equipment are depreciated over their remaining useful lives in a manner
consistent with the consumption of economic or service delivery benefits.
The Trust depreciates its non-current assets on a straight-line basis over the expected life of the asset
after allowing for the residual value. Useful lives are determined on a case by case basis. The typical
life for the following assets are:
Useful life (years)
Asset category
Freehold property - buildings
15 – 65
Freehold property - dwellings
40 – 60
Plant and machinery
5 – 25
Transport equipment
5 - 10
3-8
Information technology equipment
Furniture and fittings
4 - 15
Freehold land is considered to have an infinite life and is not depreciated.
Assets under construction and residual interests in off-statement of financial position PFI contract assets
are not depreciated until the asset is brought into use or reverts to the Trust, respectively.
Property, plant and equipment which has been reclassified as “Held for Sale” ceases to be depreciated
upon reclassification. Assets in the course of construction and residual interests in off-statement of
financial position PFI contract assets are not depreciated until the asset is brought into use or reverts to
the Trust, respectively.
Page 13
1.6
Property Plant and Equipment (cont)
Revaluations
The carrying values of property, plant and equipment assets are reviewed for impairment
when events or changes in circumstances indicate their carrying value may not be
recoverable.
Increases in asset values arising from revaluations are recognised in the revaluation
reserve, except where, and to the extent that, they reverse impairment previously
recognised in operating expenses, in which case they are recognised in operating income.
The treatment relating to decreases in asset values (known as impairments) depends on the
nature of the change in value:
(i) Economic Impairments: In accordance with the Foundation Trust Annual Reporting
Manual, impairments that are due to a loss of economic benefits or service potential in the
asset are charged to operating expenses. A compensating transfer is made from the
revaluation reserve to the income and expenditure reserve of an amount equal to the lower
of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation
reserve attributable to that asset before the impairment.
(ii) Impairments due to price changes: In these circumstances the diminution in value is
charged to the revaluation reserve to the extent that there is an available credit balance for
that asset / class of assets. Thereafter, impairments are charged to operating expenses.
Gains and losses recognised in the revaluation reserve (and not in operating expenses) are
reported in the Statement of Comprehensive Income as an item of ‘other comprehensive
income’.
iii) Impairment reversals: an impairment arising from a loss of economic benefit or service
potential is reversed when, and to the extent that, the circumstances that gave rise to the
loss is reversed. Reversals are recognised in operating income to the extent that the asset
is restored to the carrying amount it would have had if the impairment had never been
recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the
time of the original impairment, a transfer was made from the revaluation reserve to the
income and expenditure reserve, an amount is transferred back to the revaluation reserve
when the impairment reversal is recognised.
Held for sale and de-recognition
Assets intended for disposal are reclassified as ‘Held for Sale’ once all of the following
- the asset is available for immediate sale in its present condition subject only to terms
which are usual and customary for such sales;
- the sale must be highly probable i.e. management are committed to a plan to sell the
- an active programme has begun to find a buyer and complete the sale;
- the asset is being actively marketed at a reasonable price;
- the sale is expected to be completed within 12 months of the date of classification as
- 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 re-valued, 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.
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. The asset is
reviewed for impairment and the asset’s economic life is adjusted. The asset is de-
1.7
Corporation Tax
The Trust does not have a corporation tax liability for the year 2012/13.
Page 14
1.8
Donated assets
Donated and grant funded property, plant and equipment assets are capitalised at their fair value
on receipt. The donation/grant is credited to income at the same time, unless the donor imposes
a condition that the future economic benefits embodied in the grant are to be consumed in a
manner specified by the donor, in which case, the donation/grant is deferred within liabilities and
is carried forward to future financial years to the extent that the condition has not yet been met.
The donated assets are subsequently accounted for in the same manner as other items of
property, plant and equipment.
1.9
Private Finance Initiative (PFI) transactions
PFI transactions which meet the IFRIC 12 definition of a service concession, as interpreted in
Monitor's Annual Reporting Manual, are accounted for as ‘on Statement of Financial Position’ by
the Trust. The underlying assets are recognised as Property, Plant and Equipment at their fair
value. An equivalent financial liability is recognised in accordance with IAS 17. The two PFI
initiatives that are currently held on Statement of Financial Position are the Beacon Centre
(cancer facility) and the multi storey car park.
Beacon Centre
Details of the outstanding liability are provided in note 18.2. The annual contract payments are
apportioned between the repayment of the liability, a finance cost and the charges for services
and maintenance, the finance cost is calculated using the implicit interest rate for the scheme.
The Trust did not give any assets to the operator.
The service charge is recognised in operating expenses and the finance cost is charged to
Finance Costs in the Statement of Comprehensive Income.
Multi Storey Car Park
The liability relating to the multi storey car park is included in 'other liabilities' (note 17.2) and
further information about the nature of the project is included at note 18. This is a public private
partnership project (PPP). It relates to the building of a car park (completed in October 2006)
and the provision of services for 25 years. The ownership of the building will pass to the Trust
after the 25 year concession period. Throughout this period the operator collects income for car
parking fees and pays an agreed proportion of this to the Trust, no other financial transactions
take place. The Trust controls the service provided and the prices paid, consequently, the asset
is included in the Trust's Statement of Financial Position.
At the inception of the service provision (in October 2006), the cost to the operator was identified
as £6,470,000. This was introduced onto the Statement of Financial Position as a deferred PFI
credit under 'Other Liabilities'. The liability is amortised over the period of the service concession
(25 years). The annual amortised sum is credited to other income in the Statement of
Comprehensive Income. All lifecycle and replacement costs are borne by the operator and have
been modelled into the contract between the Trust and the operator. The Trust did not give any
assets to the operator. The capital value of the asset was introduced in October 2006 at the cost
to the operator and was subsequently revalued by the District Valuer.
Staff Nursery
The operator is required to provide childcare facilities over the concession period of 30 years.
The services are provided to Trust employees in the first instance and to the public thereafter.
The land was provided by the Trust on a 99 year lease. Other than this, there is no financial cost
to the Trust and no payment is received from the operator in respect of the lease. The land and
building will revert to Trust ownership at the end of the 99 year lease. The Trust does not control
the prices charged by the operator, consequently this is accounted for off Statement of Financial
Position.
Page 15
1.10
1.11
1.12
Inventories
Inventories are valued at the lower of cost and net realisable value. The cost of inventories is
measured using the weighted average cost method. A review of slow moving and obsolete stock is
carried out quarterly and written off where considered appropriate.
Cash, bank and overdrafts
Cash and bank balances are recorded at the current values of these balances in the Trust’s cash
book. These balances exclude monies held in the Trust’s bank account belonging to patients (see
"third party assets" below). Account balances are only set off where a formal agreement has been
made with the bank to do so. In all other cases overdrafts are disclosed within current liabilities.
Interest earned on bank accounts is recorded as "interest receivable" and "interest payable"
respectively in the periods to which they relate. Bank charges are recorded as expenditure in the
periods to which they relate.
Provisions
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. Where the effect of the time value of money is significant, the estimated riskadjusted cash flows are discounted using HM Treasury’s discount rate of 2.2% in real terms, except
for early retirement provisions and injury benefit provisions which both use the HM Treasury's pension
discount rate of 2.8% in real terms.
Clinical negligence costs
The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the Trust pays an
annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. 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 19. No provision is included in the accounts of the Trust for these costs.
Non-clinical risk pooling
The Trust participates in the Property Expenses Scheme (PES) 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.
Other provisions
A restructuring provision is recognised when the Trust has developed a detailed formal plan for the
restructuring and has raised a valid expectation in those affected that it will carry out the restructuring
by starting to implement the plan or announcing its main features to those affected by it. The
measurement of a restructuring provision includes only the direct expenditures arsing from the
restructuring, which are those amounts that are both necessarily entailed by the restructuring and not
associated with ongoing activities of the entity.
1.13
Contingencies
Contingent assets (that is, assets arising from past events whose existence will only be confirmed by
one or more future events not wholly within the entity's control) are not recognised as assets, but are
disclosed in note 22 where an inflow of economic benefits is probable.
Contingent liabilities are not recognised, but are disclosed in note 22, unless the probability of a
transfer of economic benefits is remote. Contingent liabilities are defined as:
Possible obligations arising from past events whose existence will be confirmed only by the
occurrence of one or more uncertain future events not wholly within the entity's control; or
Present obligations arising from past events but for which it is not probable that a transfer of economic
benefits will arise or for which the amount of the obligation cannot be measured with sufficient
reliability.
1.14
Value Added Tax
Most of the activities of the Trust are outside the scope of VAT and, in general, output tax does not
apply and input tax on purchases is not recoverable.
Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised
purchase cost of non-current assets. Where output tax is charged or input VAT is recoverable, the
amounts are stated net of VAT.
Page 16
1.15 Leases
The Trust as lessee
Finance leases
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 initial
value at which both are recognised is the lower of the fair value of the asset or the present value of the
minimum lease payments, discounted using the interest rate implicit in the lease. The implicit interest
rate is that which produces a constant periodic rate of interest on the outstanding liability.
The asset and liability are recognised at the inception of the lease, and are de-recognised when the
liability is discharged, cancelled or expires. The annual rental is split between the repayment of the
liability and a finance cost. The annual finance cost is calculated by applying the implicit interest rate to
the outstanding liability and is charged to Finance Costs in the Statement of Comprehensive Income.
Note 18.1 provides details of the finance lease that commenced in the financial year relating to the
provision of energy infrastructure assets by a private sector partner.
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.
Operating leases
Other leases are regarded as operating leases and the rentals are charged to operating expenses on a
straight-line basis over the term of the lease. Operating lease incentives received are added to the lease
rentals and charged to operating expenses over the life of the lease.
The Trust as lessor
The Trust also receives income in respect of buildings and facilities leased to third parties, these are
detailed in note 4.
Rental income from operating leases is recognised on a straight-line basis over the term of the lease.
Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying
amount of the leased asset and recognised on a straight-line basis over the lease term.
1.16 Public dividend capital
Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets
over liabilities at the time of establishment of the predecessor NHS Trust. HM Treasury has determined
that PDC is not a financial instrument within the meaning of IAS 32.
A charge, reflecting the forecast 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 and the amount included in the accounts is based on the Trust's
un-audited accounts.
Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for
donated assets, cash held with the Government Banking Service, and any PDC dividend balance
receivable or payable. In accordance with the requirements laid down by the Department of Health (as
the issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as
set out in the 'pre-audit' version of the annual accounts. The dividend thus calculated is not revised
should any adjustment to net assets occur as a result of the audit of the annual accounts.
1.17 Losses and Special Payments
Losses and Special Payments are items that Parliament would not have contemplated when it agreed
funds for the health service or passed legislation. By their nature they are items that ideally should not
arise. They are therefore subject to special control procedures compared with the generality of
payments. They are divided into different categories, which govern the way each individual case is
handled.
Losses and Special Payments are charged to the relevant functional headings in the statement of
comprehensive income on an accruals basis, including losses which would have been made good
through insurance cover had trusts not been bearing their own risks (with insurance premiums then
being included as normal revenue expenditure).
Page 17
1.18
Financial instruments
Financial assets and financial liabilities which arise from contracts for the purchase or sale of nonfinancial 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 liabilities in respect of assets acquired or disposed through finance leases are
recognised and measured in accordance with the accounting policy for leases described above.
All other financial assets and financial liabilities are recognised when the Trust becomes a party to the
contractual provisions of the instrument.
De-recognition
All financial assets are de-recognised when the rights to receive cash flows from the assets have
expired or the Trust has transferred substantially all of the risks and rewards of ownership. Financial
liabilities are de-recognised when the obligation is discharged, cancelled or expires.
Classification and Measurement
Financial assets are categorised as loans and receivables.
Financial liabilities are classified as other financial liabilities.
Loans and receivables
Loans and receivables are non-derivative financial assets with fixed or determinable payments which
are not quoted in an active market. They are included in current assets.
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.
Interest on loans and receivables is calculated using the effective interest method and credited to the
Statement of Comprehensive Income.
Financial liabilities at amortised cost
Other financial liabilities are recognised initially at fair value, net of transaction costs incurred, and
measured subsequently at amortised cost using the effective interest method. The effective interest rate
is the rate that discounts exactly estimated future cash payments through the expected life of the
financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial
liability.
They are included in current liabilities except for amounts payable more than 12 months after the
statement of financial position date, which are classified as long-term liabilities.
Interest on financial liabilities carried at amortised cost is calculated using the effective interest method
and charged to Finance Costs. Interest on financial liabilities taken out to finance property, plant and
equipment or intangible assets is not capitalised as part of the cost of those assets.
Impairment of financial assets
At the statement of financial position date, the Trust assesses whether any financial assets are
impaired. Financial assets are impaired and impairment losses are recognised if, and only if, there is
objective evidence of impairment as a result of one or more events which occurred after the initial
recognition of the asset and which has an impact on the estimated future 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 that is determined specifically on individual assets.
Page 18
1.19
Standards Issued but not yet adopted
Under International Financial Reporting, organisations are required to state those standards that
have not yet been adopted in the preparation of the accounts. The following list provides details of
the standards that are applicable from 2013/14
·
IAS 1 Presentation of financial statements (amendment).
·
IAS 12 Income Taxes (amendment).
·
IAS 19 (Revised) Employee Benefits
·
IFRS 7 Financial Instruments: Disclosures (amendment)
·
IFRS 13 Fair Value Measurement – this standard should be applicable for 2013/14,
however, HM Treasury has delayed its adoption by government bodies while it finalises some
adaptations. The impact on the financial statements is unknown until these adaptations are
finalised.
·
IAS 27 Consolidated and separate financial statements – removal of dispensation from
consolidating NHS charitable funds
·
Annual Improvements to IFRS 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.
1.20
1.21
1.22
Critical Estimates and Accounting Judgements
Note 12.1 details the revaluations to land, property, plant and equipment during the accounting
period in order to ensure that fixed assets are included in the accounts at fair value. As part of this
process, an impairment review was carried out in March 2013 in which the specialised buildings
were revalued by reference to a desk top revaluation carried out by the District Valuers of the
Revenue and Customs Government Department. Most non-property assets have not been
revalued as the Trust has judged that the carrying value of these assets is approximate to fair
value. In individual cases in which the review did reveal that cost does not approximate to fair
value, these assets have been revalued to their estimated fair value. In making this judgement,
the Trust has considered available market information as well as the presence or absence of any
key factors that would indicate an impairment. During the year, the Trust carried out a review of
the gross internal floor areas of its buildings. Any resulting changes in floor areas have been
incorporated into the valuation carried out by the District Valuer. Changes to valuations as a result
of the fair value review have been posted to the revaluation reserve or in cases in which there
were insufficient balances in the revaluation reserve to meet a diminution in value, this has been
posted to other impairments in the Statement of Comprehensive Income (SOCI).
Government Grants
Government Grants are grants from Government bodies other than income from primary care or
NHS trusts for the provision of services. Grants from the Department of Health, are accounted for
as Government grants as are grants from the Big Lottery Fund. Where the Government grant is
used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to match
that expenditure.
The donated and grant funded assets are subsequently accounted for in the same manner as
other items of property, plant and equipment. If these assets fall into the category of fixed assets,
they are carried on the Statement of Financial Position at their fair value and depreciated over
their useful economic lives. The depreciation on donated assets is treated as an operating cost
with the Statement of Comprehensive Income (SOCI).
Accounting for Joint Ventures and consolidation
During the financial year the Trust has entered into a Joint Venture partnership with Integrated
Pathology Partnerships Ltd and Yeovil District Hospital NHS Foundation Trust. The joint venture,
Southwest Pathology Services LLP (SPS), has been established to deliver and develop laboratory
based pathology services throughout the region. The interpretation of the test results remain with
the Trust, with the laboratory processing element being delivered by SPS. The Trust has retained
customer contracts for the provision of a complete pathology service with GPs, independent
sector providers and other third parties and SPS charges the Trust for the cost of processing
those tests.
Page 19
1.22
Accounting for Joint Ventures and consolidation (cont)
It has been deemed to be a joint venture agreement because the SPS articles have been structured so
that all significant decisions require all three parties to agree. SPS has therefore been consolidated on
the equity basis under IAS 31.
The investment is initially recognised at cost. It is increased or decreased subsequently to reflect the
Trust’s share of the entity’s profit or loss or other gains and losses. The Trust has recognised 51% of
the joint ventures profits / share of net assets in its accounts which reflects the percentage of ownership
in SPS.
The charitable funds of the Trust are considered to be a subsidiary under IAS 27. However, following
HM Treasury dispensation from this requirement, the charitable funds have not been consolidated into
these accounts for 2012/13.
2
Segmental Reporting
Operating segments are reported in a manner consistent with the internal reporting provided to the
chief operating decision-maker. The chief operating decision-maker, who is responsible for allocating
resources and assessing performance of the operating segments has been identified as the board that
makes strategic decisions. The Taunton and Somerset NHS Foundation Trust is managed by the Board
of Directors, which is made up of both Executive and Non-Executive Directors. The Board is
responsible for strategically and operationally leading the work of the hospital. The Non-Executive
Directors bring external expertise to the organisation and provide advice and guidance to the Executive
Directors. The Executive Directors take care of the day to day running of the hospital.
The Board is therefore considered to be the Chief Operating Decision Maker (CODM) of the hospital.
The monthly financial information presented to the Board includes a Trust level Statement of
Comprehensive Income, a Statement of Financial Position, a Statement of Cash flows and other
financial indicators such as the financial risk rating for the majority of 2012/13. The segmental
expenditure data is included in the overall performance report by way of a separate note which
summarises the contributions of the divisions, and separately identifies reserves and central budgets. In
2012/13 this will focus down to a directorate level. The detail includes current period and year to date
data, in each case comparing actual data to plan. The commentary also includes the Division's
contribution to Trust wide initiatives, such as cost improvement programmes. Other information
reported to the Board is specifically analysed for its purpose, for example Trust pay spend against
budget analysed by employee groups and income stream expectations by type (NHS Clinical, non NHS
etc) compared to actual achieved. Information such as delivery of the savings plan is a Trust wide
position paper but detailed into the areas tasked with implementing savings.
The Trust has used three key factors in its identification of its reportable operating segments. The key
factors are that the reportable operating segment:
a) engages in activities from which it earns revenues and incurs expenses;
b) reports financial results which are regularly reviewed by the Trust's board of directors to make
decisions about allocation of resources to the segment and to assess its performance;
c) has discrete financial information.
The Trust's reportable segments and services provided are:
Emergency and Urgent Care
The services provided by this operating segment include acute emergency medical activity including
accident and emergency services and medical assessment for acutely ill patients, prior to admission to
specialist areas such as Care of the Elderly, Stroke, Cardiology, Respiratory, Neurology or
Endocrinology. These specialities also undertake routine non-emergency outpatient activity and
appropriate diagnostic and therapeutic procedures as required. The segment also provides maternity
services and paediatric activity including operation of a neonatal intensive care unit. General surgery
provides both outpatient, diagnostic, day-case and inpatient services incorporating both emergency and
non-emergency operations and has specific sub-specialisms in vascular, upper and lower gastrointestinal surgery.
Page 20
Planned Care
The services provided by this operating segment include inpatient and outpatient care for orthopaedic, ENT,
Max Fax, dermatology, GUM, ophthalmology, rheumatology, pain, orthodontics and urology. In addition the
division provides the Trust cancer services and theatre facilities. This includes a dedicated cancer and
radiotherapy centre and range of theatres.
Clinical Support
The services provided by this operating segment are generally support services to other specialties within the
Trust and include Medical Imaging, Pathology, Pharmacy and Therapies and site wide services such as hard
and soft facilities management.
Corporate
This segment provides corporate management for the Trust and includes the Trust Board, Finance and
Information, Organisational Development, Performance Development, Nursing and Governance, Medicine,
IM&T (incl. Somerset Health Informatics) and Education and Training.
Other
Certain central budgets were not reported separately and are therefore included in the reconciliation to the
Statement of Comprehensive Income provided below.
Segmental Analysis
The segmental data provided to the Board in 2012/13 changed from that provided previously. The main
difference is that clinical income is now included in the segmental reporting. Therefore, the tables below show
the information provided in each year together with a reconciliation to the Statement of Comprehensive
Income.
For the year ended 31 March 2013
Emergency
and Urgent
Care
Planned
Care
Clinical
Support
Corporate
£000
£000
£000
£000
112,050
(19,183)
(60,978)
31,889
96,880
(30,744)
(47,238)
18,898
23,036
(35,077)
(25,195)
(37,236)
13,080 245,046
(5,959) (90,963)
(20,278) (153,689)
(13,157)
394
Total
£000
Operating Expenses from continuing operations
Income
Non-Pay Costs
Pay Costs
Total income / (expenditure)
Reconciliation to Statement of Comprehensive Income
Education Income
Research and Development Income
PDC dividends
Impairments
Interest Received
Total Interest Payable On Loans And Leases
Loss On Asset Disposals
Other adjustments
Surplus
Page 21
6,641
1,577
(3,862)
(2,893)
313
(1,586)
(13)
(100)
471
For the year ended 31 March 2012
Emergency
and Urgent
Care
Planned
Care
Clinical
Support
Corpora
te
£000
£000
£000
£000
93,491
(29,912)
(45,816)
17,763
20,818
5,284
(24,913) (5,246)
(27,958) (15,410)
(32,053) (15,372)
Total
£000
Operating Expenses from continuing operations
Income
Non-Pay Costs
Pay Costs
Total income / (expenditure)
110,927
(18,851)
(58,583)
33,493
Reconciliation to Statement of Comprehensive Income
Education Income
Research and Development Income
PDC dividends
Impairments
Interest Received
Total Interest Payable On Loans And Leases
Other adjustments
Surplus
230,520
(78,922)
(147,767)
3,831
6,675
1,738
(3,962)
(482)
321
(1,329)
(5,283)
1,509
Transactions between segments are made at cost and netted off against the appropriate expenditure
The Trust operates solely in the UK. Patients who do not live in the UK are treated via reciprocal
arrangements or are required to pay for their own treatment. £8,900 (2011/12: £5,000) came from patients
who do not live in the UK.
The Trust provides elective, non elective, outpatient and A&E services. The majority of these services are
funded by Primary Care Trusts, which provide 87% of the Trust's income. Income is also generated from
providing private patient treatment which represents less than 1% of total Trust income. Income from
overseas based patients is negligible. Other income generated by the Trust includes educational and
training grants. Note 4 provides a detailed breakdown of the funding streams.
Page 22
3
Operating Income
3.1
Income from activities by activity
2012/13
£000
2011/12
£000
41,212
65,080
40,631
5,816
67,745
1,330
3,887
45,120
65,093
39,165
5,296
55,575
1,548
5,635
225,701
217,432
Income from activities by customer type
2012/13
£000
2011/12
£000
NHS Foundation Trusts
NHS Trusts
Primary Care Trusts
Local Authorities
Department of Health - grants
NHS Other
Non NHS: Private patients
Non-NHS: Overseas patients (non-reciprocal)
NHS Injury Scheme (was RTA)
Non NHS: Other
413
220,334
701
758
1,330
684
1,481
1,756
1
211,268
0
0
0
1,548
5
653
2,201
225,701
217,432
Elective income
Non-elective income
Outpatient income
A&E income
Other mandatory NHS clinical income
Private patient income
Other non-mandatory clinical income
3.2
The NHS Injury Scheme income is subject to a provision for doubtful debts of 12.6% (10.5% in
2011/12) to reflect expected rates of collection.
3.3
Private Patient Income
The statutory limitation on private patient income in section 44 of the 2006 Act was repealed with
effect from 1 October 2012 by the Health and Social Care Act 2012. The financial statements
disclosures that were provided previously are no longer required.
4
Other Operating Income
4.1
Other operating income comprises
2012/13
2011/12
£000
£000
1,577
6,641
876
14,339
675
1,738
6,675
463
10,686
1,196
Reversal of impairments of property, plant and equipment
Rental revenue from operating leases
431
188
427
Amortisation of PFI deferred credits Car Park
259
259
5,823
30,621
5,563
27,195
Research and development
Education and training
Charitable and other contributions to expenditure
Non-patient care services to other bodies *
Other income
Income relating to staff costs accounted for gross
Total other operating income
* Non patient care services to other bodies includes income for Pharmacy, Estates, HR and IT
services provided to other NHS bodies.
Page 23
4.2
Other Income comprises
Clinical excellence awards
Catering
Other
Total
5
Operating Expenses
5.1
Operating expenses comprise:
Services from Foundation Trusts
Purchase of healthcare from non NHS bodies
Executive Directors costs
Non-Executive Directors costs
Staff costs
Drug costs
Supplies and services - clinical
Supplies and services - general
External Pathology Services
Establishment
Transport
Premises
Increase in general provisions
Increase in provision for impaired receivables
Depreciation on property, plant and equipment
Amortisation on intangible assets
Impairments of property, plant and equipment
Audit fees:
audit services - statutory audit
audit services - regulatory reporting
irrecoverable VAT in connection with Audit services
Other auditors remuneration
Clinical negligence
Loss on disposal of other property, plant and equipment
Legal fees
Consultancy costs
Training, courses and conferences
Patient travel
Redundancy
Insurance
Losses, ex gratia and special payments
Other
Total
2012/13
£000
2011/12
£000
648
0
27
675
647
549
0
1,196
2012/13
£000
2011/12
£000
2,267
103
1,064
137
154,995
20,862
25,282
3,289
9,080
2,373
1,388
10,613
131
183
8,342
171
2,893
2,581
337
1,100
134
152,976
18,954
25,912
4,524
0
2,477
1,486
10,313
340
157
7,934
166
670
66
137
24
22
4,512
13
289
563
870
187
551
167
9
14
44
16
12
0
4,430
36
622
677
1,031
180
459
251
126
180
250,597
238,125
Research and Development expenditure in the year was £1,576,000 (2011/12 £1,720,000). This is included in
supplies and services general and staff costs
Page 24
5.2
Arrangements containing an operating lease
5.2.1 Minimum lease payments made
31 MARCH
2013
£000
180
180
Minimum lease payments
Total
31 MARCH
2012
£000
452
452
These costs are included within operating expenses categories of transport and premises.
5.2.2 Future operating lease obligations
31 MARCH 2013
Land &
buildings
Future minimum lease payments due:
Not later than one year
143
Later than one year and not
later than five years
406
Later than five years
2,371
Total
2,920
5.3
Other
31 MARCH 2012
Land &
Total
Total buildings Other
£000
£000
101
244
143
191
334
80
0
181
486
2,371
3,101
406
2,514
3,063
297
26
514
703
2,540
3,577
Limitation on auditors' liability
Disclosure is required by the Companies (Disclosure of Auditor Remuneration and Liability Limitation
Agreements) Regulations 2008, where the Trust's contract with it's external auditors provides for a
limitation of the auditors' liability.
The Board of Governors appointed PricewaterhouseCoopers LLP (PWC) as external auditors from the
financial year 31 March 2010 onward. The engagement letter signed on 9 April 2009 and updated in
2012/13 states that the liability of PWC, its members, partners and staff (whether in contract, negligence
or otherwise) shall in no circumstances exceed £1 million in the aggregate in respect of all services
(2011/2012 £1m).
5.4
The Late Payments of Commercial Debts (Interest) Act 1998
During the financial year, there were no significant interest payments relating to the late payment of
commercial debt (2011/12 £Nil).
6
6.1
Staff costs
Staff costs
Salaries and wages
Social security costs
Employers contributions to NHS Pensions
Termination benefits
Agency and contract staff
Total
2012/13
£000
2011/12
£000
120,879
10,302
14,990
551
9,888
156,610
121,026
9,450
15,223
459
8,794
154,952
Staff costs include the arrangement with SHAs for the Psychology students hosting arrangement
Page 25
6.2
Exit package cost band (including special payments)
Number of
compulsory
redundancies
<£10,000
£10,001 - £25,000
£25,001 - 50,000
£50,001 - £100,000
6.3
2
0
2
0
4
Total exit
Cost of special
packages
Number of other
number and payments made
departures
(£)
(value)
agreed
0
36 38 (£138,000)
0
10 10 (£131,000)
4 6 (£190,000)
0
1 (£92,000)
1
0
51 55 (£551,000)
0
Average monthly number of persons employed (WTE basis)
Hospital medical and dental staff
Administration and estates staff
Healthcare assistants and other support staff
Nursing, midwifery and health visiting staff
Scientific, therapeutic and technical staff
Total
6.4
2012/13
Number
2011/12
Number
448
846
429
1,478
582
3,783
439
879
456
1,452
638
3,864
Directors' remuneration and other benefits
The aggregate remuneration and other benefits receivable by Directors during the financial year
totalled £933,177 (2011/12 £1,099,834). The highest paid Director, taking into account emoluments for
their role as a Director only, was Mrs J Cubbon with a salary of £166,819.
Benefits are accruing under the NHS defined benefit pension scheme to eight of the Directors. No
benefits are accruing under any money purchase schemes.
There were no other advances or guarantees existing with any of the Directors as at 31 March 2013.
7
Early retirements due to ill-health
During the year from 1st April 2012 to 31 March 2013 there was one early retirement from the Trust on
the grounds of ill-health (three in the year to 31 March 2012). The estimated additional pension
liabilities of these ill-health retirements is £46,300 (£139,000 in the year to 31 March 2012). The cost of
these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division.
8
Finance income
Bank interest
Total
9
2012/13
£000
2011/12
£000
313
313
321
321
2012/13
£000
2011/12
£000
270
57
1,259
19
1,605
7
0
1,322
23
1,352
Finance expense - financial liabilities
Finance leases
Other
Finance costs for PFI obligations
Unwinding of Discounts on provisions (note 19)
Page 26
10
Impairment of assets (PPE and intangibles) - recognised in income and expenditure
Future demolition of buildings
Changes in market price
Reversals of impairments
Total impairments
2012/13
£000
2011/12
£000
0
2,893
0
2,893
41
629
(188)
482
The impairments comprise £793,000 relating to a general reduction in the value of the Trust's buildings
identified by the valuation carried out by the District Valuer. These impairments have been treated as
income and expenditure items within the Statement of Comprehensive Income because there is no
available balance within the revaluation reserve for these items to offset against the fall in value. The
remaining £2,100,000 represents a write down of the Jubillee building asset in construction due to
estimates of its value in use being more than the cost of construction. A proportion of the impairment,
equivalent to the proportion of completion, has been brought into the 2012/13 accounts.
11.1
2012/13
Software
licences
£000
2011/12
Software
licences
£000
1,142
102
1,244
837
305
1,142
Accumulated Amortisation at 1 April 2012
Provided during the year
Accumulated Amortisation at 31 March 2013
537
171
708
371
166
537
Net book value
- Purchased at 1 April 2012
- Donated at 1 April 2012
- Total at 1 April 2012
605
0
605
457
9
466
- Purchased at 31 March 2013
- Donated at 31 March 2013
- Total at 31 March 2013
536
0
536
605
0
605
Intangible Assets
Fair value at 1 April 2012
Additions purchased
Fair value at 31 March 2013
All short life assets including intangibles are carried at depreciated historic cost as a proxy to fair value.
Page 27
12.1
Property, Plant and Equipment 2012/13
Land
Freehold
Buildings
(excluding
dwellings)
Freehold
Dwellings
Assets under
construction and
payments on
account
Plant and
machinery
Transport
equipment
Information
technology
equipment
Furniture and
fittings
Total
£000
£000
£000
£000
£000
£000
£000
£000
£000
18,684
0
0
0
0
0
18,684
99,759
1,319
0
(1,669)
561
0
99,970
3,099
0
0
(75)
149
0
3,173
9,873
16,140
0
0
(3,714)
0
22,299
42,645
6,660
627
0
2,753
(1,521)
51,164
98
0
0
0
0
0
98
12,073
496
0
0
0
0
12,569
3,326
788
246
0
251
0
4,611
189,557
25,403
873
(1,744)
0
(1,521)
212,568
0
0
0
0
0
0
8,445
3,877
793
640
0
13,755
125
75
0
0
0
200
640
0
2,100
(640)
0
2,100
25,175
3,105
0
0
(1,115)
27,165
74
7
0
0
0
81
9,546
1,014
0
0
0
10,560
2,196
264
0
0
0
2,460
46,201
8,342
2,893
0
(1,115)
56,321
Net book value
- Owned at 1 April 2012
- Finance lease at 1 April 2012
- PFI as at 1 April 2012
NBV total at 1 April 2012
18,684
0
0
0
18,684
72,678
0
17,831
805
91,314
2,974
0
0
0
2,974
9,233
0
0
0
9,233
12,405
2,535
1,365
1,165
17,470
11
13
0
0
24
2,251
0
276
0
2,527
730
373
0
27
1,130
118,966
2,921
19,472
1,997
143,356
- Owned at 31 March 2013
- Finance leased as at 31 March 2013
- PFI as at 31 March 2013
NBV total at 31 March 2013
18,684
0
0
0
18,684
68,704
0
16,747
764
86,215
2,973
0
0
0
2,973
20,199
0
0
0
20,199
13,557
7,500
1,115
1,827
23,999
11
6
0
0
17
1,804
0
205
0
2,009
2,151
0
0
0
2,151
128,083
7,506
18,067
2,591
156,247
Analysis of Property, Plant and Equipment 31 March 2013
Net book value
Protected assets at 31 March 2013
Unprotected assets at 31 March 2013
Total at 31 March 2013
17,951
733
18,684
84,286
1,929
86,215
1,566
1,407
2,973
0
20,199
20,199
0
21,190
21,190
0
17
17
0
2,009
2,009
0
4,960
4,960
103,803
52,444
156,247
Additions purchased
Additions donated
Impairments charged to revaluation reserve
Reclassifications
Disposals
Accumulated depreciation at 1 April 2012
Impairments recognised in operating expenses
Reclassifications
Disposals
Accumulated depreciation at 31 March 2013
During the financial year the Trust acquired assets of £876,000 through donations (£311k in 2011/12), these are included in the overall net book value of donated assets at 31st March 2013 which
approximates to fair value. There are no restrictions or conditions imposed by the donor on the use of these assets.
Page 28
12.2
Property, Plant and Equipment 2011/12
Land
Freehold
Buildings
(excluding
dwellings)
Freehold
Dwellings
Assets under
construction and
payments on
account
Plant and
machinery
Transport
equipment
Information
technology
equipment
Furniture and
fittings
Total
£000
£000
£000
£000
£000
£000
£000
£000
£000
18,952
0
0
0
0
(28)
(240)
18,684
96,384
0
0
16
0
3,359
0
99,759
3,318
0
0
0
0
206
(500)
3,024
7,012
3,559
0
0
(698)
0
0
9,873
38,317
3,327
304
0
818
0
(121)
42,645
372
12
0
0
(286)
0
0
98
11,606
301
0
0
166
0
0
12,073
2,759
572
7
0
0
0
(12)
3,326
178,720
7,771
311
16
0
3,537
(873)
189,482
0
0
0
0
0
0
0
4,721
3,653
259
(188)
0
0
8,445
75
79
0
0
0
(29)
125
640
0
0
0
0
0
640
22,126
2,757
411
0
(4)
(115)
25,175
68
6
0
0
0
0
74
8,343
1,199
0
0
4
0
9,546
1,967
240
0
0
0
(11)
2,196
37,940
7,934
670
(188)
0
(155)
46,201
Net book value
- Owned at 1 April 2011
- Finance lease at 1 April 2011
- PFI as at 1 April 2011
NBV total at 1 April 2011
18,952
0
0
0
18,952
73,035
0
17,775
853
91,663
3,318
0
0
0
3,318
6,372
0
0
0
6,372
13,504
0
1,614
1,073
16,191
286
18
0
0
304
2,915
0
348
0
3,263
778
0
0
14
792
119,160
18
19,737
1,940
140,855
- Owned at 31 March 2012
- Finance leased as at 31 March 2012
- PFI as at 31 March 2012
18,684
0
0
0
72,678
0
17,831
805
2,974
0
0
0
9,233
0
0
0
12,405
2,535
1,365
1,165
11
13
0
0
2,251
0
276
0
730
373
0
27
118,966
2,921
19,472
1,997
NBV total at 31 March 2012
18,684
91,314
2,974
9,233
17,470
24
2,527
1,130
143,356
Analysis of Property, Plant and Equipment 31 March 2012
Net book value
Protected assets at 31 March 2012
Unprotected assets at 31 March 2012
Total at 31 March 2012
17,951
733
18,684
89,341
1,973
91,314
1,545
1,429
2,974
0
9,233
9,233
0
17,470
17,470
0
24
24
0
2,527
2,527
0
1,130
1,130
108,837
34,519
143,356
Additions purchased
Additions donated
Impairments charged to revaluation reserve
Reclassifications
Revaluation surpluses
Disposals
Accumulated depreciation at 1 April 2011
Impairments recognised in operating expenses
Reversal of impairments
Reclassifications
Disposals
Accumulated depreciation at 31 March 2012
Page 29
12.3
Economic Life of Property, Plant and Equipment
Minimum
Life
(years)
Infinite
15
40
5
5
3
4
Land
Buildings excluding dwellings
Dwellings
Plant and Machinery
Transport Equipment
Information Technology
Furniture and Fittings
Maximum
Life
(years)
Infinite
65
60
25
10
8
15
Of the total value of land, buildings and dwellings of £107,802,000 (2011/12 £112,972,000),
£1,100,000 (2011/12 £1,100,000) was held on long leasehold. Assets that were held under Finance
Leases are detailed in note 18.
13
Revaluation of assets and Impairment Review
13.1
Land, Buildings and Dwellings
During the accounting period a desktop valuation was undertaken to revalue the land, buildings and
dwellings on the basis of modern equivalent asset valuations, this updated the valuation review
undertaken in 2011/12. The valuation was carried out by an independent valuer, the District Valuer and
the effective date of the valuation was 31 March 2013. The valuation was carried out in accordance
with the terms of the Royal Institute of Chartered Surveyors valuation standard and in accordance with
the revaluation model set out in IAS 16.
This identified an overall decrease in values of the Trust's specialist buildings of £1,819,000 (nil for
land) and an increase of £75,000 for dwellings. The bulk of these movements have been accounted
for as revaluations in the revaluation reserve (£1,744,000) in the Statement of Changes in Taxpayers'
Equity. The revaluation formed part of an overall impairment review which identified price impairments
of £2,500,000 for operation assets and a partial impairment on the Jubilee Build, an asset under
construction of £2,100,000. Of this decrease £793,000 of net impairments of specialist property which
have been included in operational expenses (note 5.1). The valuation is based on an estimation carried
out by the District Valuer as part of the overall review in March 2013 and is included in the above
figures.
13.2
Non Property Assets
An impairment review was carried out in March 2013 to review the values at which non property assets
are carried in the SOFP. The exercise involved a comparison of the 64 highest value items (accounting
for 93% of the overall value of non property assets). The review identified that for all of these assets
the carrying value was not significantly different to fair value, therefore, in these cases, no revaluation
adjustment has been made.
14
Non Current assets held for sale
No non-current assets were held for sale at the financial year end.
15
Inventories
Inventories carried at fair value less costs to sell
Total
31 MARCH
2013
£000
2,743
2,743
31 MARCH
2012
£000
2,850
2,850
Inventories recognised in expenses in the period
Total
25,149
25,149
22,086
22,086
Page 30
16
16.1 Trade and other receivables
Current
NHS receivables
Other receivables with related parties
Provision for impaired receivables (note 16.2)
Prepayments
Accrued income
PDC receivable
Other receivables
Total current trade and other receivables
Non Current
NHS receivables
Total non current trade and other receivables
TOTAL RECEIVABLES
31 MARCH
2013
£000
31 MARCH
2012
£000
2,856
1,824
(354)
694
2,679
161
1,983
9,843
4,829
1,728
(428)
651
2,138
21
1,297
10,236
0
0
284
284
9,843
10,520
2012/13
£000
2011/12
£000
428
183
(257)
0
354
1,284
820
(1,013)
(663)
428
16.2 Provision for impairment of receivables
Opening balance
Increase in provision
Amounts utilised during the year
Unused amounts reversed
Closing balance
The Trust's policy is to impair specific debts to the extent to which it considers they may not be fully
recoverable. Those debts not impaired by the Trust are considered to be collectable and of good credit
quality.
16.3 Analysis of impaired receivables
Ageing of impaired receivables
Up to three months
In three to six months
Over six months
Total
Ageing of non-impaired receivables past their due date
0-30 days
30-60 days
60-90 days
90-180 days
over 180 days
Total
Page 31
31 MARCH
2013
£000
31 MARCH
2012
£000
0
212
142
354
29
13
386
428
9,196
137
81
75
0
9,489
8,759
5
115
765
448
10,092
17
17.1
Trade and other payables at the SoFP date are made up of:
31 MARCH 2013
£000
31 MARCH 2012
£000
525
1,994
3,104
3,227
3,099
2,460
4,950
19,359
813
1,913
871
1,648
3,217
3,647
4,825
16,934
82
82
83
83
19,441
17,017
31 MARCH 2013
£000
31 MARCH 2012
£000
Current
Deferred income
Deferred PFI credits, multi storey car park
Total other current liabilities
1,396
259
1,655
1,313
259
1,572
Non-current
Deferred PFI credits, multi storey car park
Total other non-current liabilities
4,529
4,529
4,787
4,787
TOTAL OTHER LIABILITIES
6,184
6,359
Current
NHS payables
Amounts due to other related parties
Trade payables - capital
Other trade payables
Taxes and social security payable
Other payables
Accruals
Total current trade and other payables
Non-current
Trade payables - capital
Total non-current trade and other payables
TOTAL TRADE AND OTHER PAYABLES
17.2
Other liabilities
Multi Storey Car Park
Deferred PFI credits are amortised over the 25 year concession term. This amounted to
£259,000 in each of the years above. There are no restrictions or contingent rents.
17.3
Borrowings
Current
Loan from Foundation Trust Financing Facility
Obligations under finance leases
Obligations under PFI contracts
31 MARCH 2013
£000
31 MARCH 2012
£000
648
419
101
1,168
0
263
703
966
11,352
6,488
0
2,685
13,985
31,825
14,086
16,771
32,993
17,737
Non-Current
Loan from Foundation Trust Financing Facility
Obligations under Private Finance Initiative
contracts
TOTAL BORROWINGS
The above borrowings relate to finance lease liabilities for items of plant and equipment
including those obtained via the energy project (see note 18 below) and the liability for the
Beacon centre cancer facility (see note 18.2 below).
Page 32
17.4
31 MARCH
2013
£000
31 MARCH
2012
£000
31 MARCH
2011
£000
Total Prudential Borrowing Limit
52,000
12,700
64,700
53,800
12,700
66,500
46,100
12,700
58,800
Long term borrowing at 1 April
Net actual borrowing in year - long term
Long term borrowing at 31 March
17,737
15,256
32,993
15,411
2,326
17,737
16,114
(703)
15,411
Working capital borrowing at 1 April
0
0
0
Net actual borrowing in year - working capital
Working capital borrowing at 31 March
0
0
0
0
0
0
Prudential Borrowing Limit
Total long term borrowing limit set by Monitor
Working capital facility agreed by Monitor
Note: the actual (contracted) working capital facility in place with the Trust's bankers, National Westminster Bank
PLC, at 31st March 2013 amounts to £5,000,000
17.5
Financial Ratios
2012/13
2012/13
2011/12
2011/12
Actual
Ratios
Planned
Ratios
Actual
Ratios
Planned
Ratios
Minimum Dividend Cover
4
4
4
3
Minimum Interest Cover
11
11
8
9
Minimum Debt Service Cover
Maximum Debt Service to Revenue
5
5
4
5
0.01%
0.01%
0.02%
0.01%
The NHS Foundation Trust is required to comply and remain within a Prudential Borrowing Limit. This is made up of
two elements :
a) the maximum cumulative amount of long-term borrowing. This is set by reference to the four ratio tests set out in
Monitor's Prudential Borrowing Code. The financial risk rating set under Monitor's Compliance Framework
determines one of the ratios and therefore can impact on the long term borrowing limit.
b) The amount of any working capital facility approved by Monitor.
Further information on the NHS Foundation Trust Prudential Borrowing code and Compliance Framework can be
found on the website of Monitor, the Independent Regulator of Foundation Trusts.
18
Obligations Under Finance Leases and Private Finance Initiatives
18.1
Finance lease obligations
Gross lease liabilities
31 MARCH 2012
31 MARCH 2013
Energy
£000
Portering
£000
Total
£000
Energy
£000
Portering
£000
Total
£000
10,560
0
10,560
3,954
3
3,957
960
0
960
361
3
364
3,840
0
3,840
1,437
0
1,437
5,760
0
5,760
2,156
0
2,156
(3,653)
6,907
0
0
(3,653)
6,907
(1,008)
2,946
(1)
2
(1,009)
2,948
419
0
419
261
2
263
2,028
4,460
6,907
0
0
0
2,028
4,460
6,907
743
1,942
2,946
0
0
2
743
1,942
2,948
of which liabilities are due:
- not later than one year;
- later than one year and not later
than five years;
- later than five years.
Finance charges allocated to future
periods
Net lease liabilities
of which liabilities are due:
- later than one year and not later
than five years;
Page 33
Net Book Value of non PFI assets held on finance
leases
Portering vehicles and cytology equipment
Energy Project
31 MARCH
2013
£000
31 MARCH
2012
£000
0
7,500
7,500
13
2,908
2,921
The above leasing commitments are finance leases in respect of portering vehicles and other
equipment: £13,000 in 2011/12 and energy infrastructure: The differences between the net book
value of assets held under finance leases and finance lease obligations comprises capital
repayments, interest charges and asset depreciation.
Leases for portering vehicles: These are standard leases paid in periodic fixed payments and
there are no restrictions or renewable options.
Leases for energy infrastructure: During 2011/12 the Trust entered into a contract with a
private sector partner, Schneider Electric for the provision and installation of energy
infrastructure assets. The total value of the contract will be £7,867,000 and the installation work
commenced in June 2011 and was completed during the 2012/13 financial year. The overall
leasing commitment for the contract will amount to £7,867,000 and repayments commenced in
December 2012 and will be paid annually over the 12 year term of the lease. This is a standard
lease paid in periodic fixed annual payments and there are no restrictions or renewable options.
18.2
Private Finance Initiative obligations
31 MARCH
2013
Total
£000
31 MARCH
2012
Total
£000
Gross PFI liabilities are due:
- later than one year and not later than five years;
Total Gross Liabilities
1,305
5,092
29,301
35,698
1,967
6,936
28,762
37,665
Net PFI liabilities are due:
- later than one year and not later than five years;
Total Net Liabilities
101
686
13,299
14,086
703
2,331
11,755
14,789
(21,612)
(22,876)
Reconciliation between Net Book values of PFI assets
Net Liability (as above)
Revaluations and impairments
Repayments / amortisation of capital sum
Depreciation
14,086
(1,592)
2,412
(2,195)
14,789
(934)
1,709
(1,699)
Net Book Value of PFI Assets held on finance leases
12,711
13,865
Timing of liabilities:
Finance charges allocated to future periods
Page 34
The PFI obligation above relates to the Beacon Centre (cancer facility) which opened in May 2009. The
accounting entries relating to the multi storey car park are dealt with in note 17.2, Other Liabilities.
Future commitments for PFI schemes
The Trust is committed to make the following payments for on-SoFP PFIs obligations (relating to the Beacon
Centre) during the next year in which the commitment expires:
31 MARCH
31 MARCH
2012
2013
Total
Total
£000
£000
26th to 30th years (inclusive)
18.3
3,347
3,235
3,347
3,235
Private Finance Transactions
a) The Beacon Centre
The project agreement is with the Taunton Linac Company Limited (the operator) for the provision of an
Oncology and Haematology Centre on the Musgrove Park Hospital site (The Beacon Centre) including the
supply and maintenance of the building and major medical equipment within the facility. The facility opened in
May 2009 and provides state of the art non-surgical cancer services to the residential population of Somerset,
in a suitable location and setting at Taunton and Somerset NHS Foundation Trust. The new Oncology and
Haematology Centre provides:
- Two Linear Accelerators (a third has been purchased by the Trust)
- One simulation suite with processing and treatment planning facilities
- 18 bed Oncology Ward
- Chemotherapy suite for 22 day patients
- Outpatients suite with 4 consulting and 8 examination rooms
Key Features of the Scheme:
In return for an agreed monthly payment, the following facilities are provided to the Trust by the Operator plus
associated hard FM and asset renewal services:
- Inpatient and Outpatient facilities
- Radiotherapy treatment area
- Administrative offices
- Public spaces
Under the Project Agreement, the above facilities are provided at a pre-determined level of quality for the 30
year term (excluding the construction period).
The operator has also procured, installed, and will maintain and replace major medical equipment for the full 30
years of the operating period. The major equipment requirements include two Linear Accelerators. However,
soft FM services such as portering, catering and cleaning are provided by the Trust and are outside the scope
of this PFI project.
Nature of Payment
The Operator provides the services in return for an annual service charge. In covering payment for facilities,
other services and financing, the annual service charge is unitary in nature. The Trust has agreed a payment
mechanism that incorporates the principles of the NHS Standard Form contract. This relates payment to the
successful (or otherwise) achievement of the service and quality standards set out in the output specification.
The unitary payment can be abated for instances of non-performance against the standards in the output
specification up to a maximum of 100% of the unitary fee, which fall into three areas:
i) Failure events – where there is a failure to meet a specific service standard relating to a particular area of
the hospital.
ii) Failure events – relating to the Radiotherapy Equipment.
iii) Quality failures – where there is a failure to supply a service across a wider range of parameters, which
cannot be attributed to a specific area of the hospital.
The unitary payment relating to the Beacon Centre is set by the contract between the Trust and the operator
and is subject to an inflationary uplift based on the Retail Price Index (RPI). The total unitary payment for
2012/13 amounted to £3,235,000 for 2013/14 will be £3,347,000. The value of the liability at 31 March 2013
was £14,086,000 and the net book value of the asset was £12,711,000. Note 18.2 provides a reconciliation
between these two figures.
Page 35
Property ownership
The site on which the new Oncology facilities have been built is in the freehold ownership of the Trust.
Expiry of contract
On expiry of the contract (May 2039), the facility will revert to the ownership of the Trust for no payment.
b)
Provision of Multi Storey Car Park
This is a public private partnership project (PPP). It relates to the building of a car park (completed in
October 2006) and the provision of services for 25 years. The ownership of the building will pass to the
Trust after the 25 year concession period. The residual value (assessed by professional valuation) is
£4,468,000. Throughout this period the operator pays an agreed proportion of the car parking fees to the
Trust, no other financial transactions take place. Since 2009/10 this has been accounted for under
International Financial Reporting Standards and the asset together with the outstanding liability is required
to be accounted for in the Statement of Financial Position. The asset and liability are summarised below:
31 MARCH 31 MARCH
2012
2013
£000
£000
Net Book Value of asset (included in property, plant and equipment, note 12.1)
Liability (see deferred PFI credits, note 17.2)
5,356
5,606
4,788
5,046
c)
Staff Nursery
This is accounted for off Statement of Financial Position. The operator is required to provide childcare
facilities over the concession period, of 30 years from 2003, therefore the arrangement has 20 years to run.
The services are provided to Trust employees in the first instance and to the public thereafter. The land
was provided by the Trust on a 99 year lease. Other than this, there is no financial cost to the Trust. The
land and building will revert to Trust ownership at the end of the 99 year lease.
19
Provisions for liabilities and charges
a)
Financial Year 2012/13
At 1 April 2012
Arising during the year
Utilised during the year
Reversed unused
Unwinding of discount
At 31 March 2013
Expected timing of cash flows:
- not later than one year
- later than one year and not later than
five years
- later than five years
Total
b)
Financial Year 2011/12
At 1 April 2011
Arising during the year
Utilised during the year
Reversed unused
Unwinding of discount
At 31 March 2012
Expected timing of cash flows:
- not later than one year
- later than one year and not later than
five years
- later than five years
Total
Pre 1995
Early
Retirements
£000
Personal
Injury
Claims
£000
Injury
Benefit
Claims
£000
Other
£000
Total
£000
252
37
(22)
0
6
273
71
47
(49)
0
0
69
566
47
(39)
0
13
587
228
0
0
0
0
228
1,117
131
(110)
0
19
1,157
21
69
38
228
356
81
171
273
0
0
69
142
407
587
0
0
228
223
578
1,157
Pre 1995
Early
Retirements
£000
256
10
(21)
0
7
252
Personal
Injury
Claims
£000
54
115
(52)
(46)
0
71
Injury
Benefit
Claims
£000
554
33
(37)
0
16
566
Other
£000
0
228
0
0
0
228
Total
£000
864
386
(110)
(46)
23
1,117
20
71
37
228
356
76
156
252
0
135
394
566
0
0
228
211
550
1,117
71
Page 36
19
Provisions note (continued)
Pre 1995 early retirements are calculated on figures supplied by the NHS Pensions Agency and a
significant amount of the payments are expected to be greater than one year. The Personal Injury
provisions are based on the expected values and probabilities quantified by the NHSLA. The outcome of
these cases are inherently uncertain and the timing of payments is dependant on the progression of each
case. The figures included in the summary are based purely on the Trust's excess reflecting the fact that
the NHSLA make the majority of payments direct. The Injury Benefit provisions are based on figures
supplied by the NHS Pensions Agency a significant amount of the payments are expected to be greater
than 1 year. Other provisions, established in 2011/12, relates to a potential backdated charge by HMRC
for PAYE and national insurance.
Clinical Negligence liabilities
£43,404,253 is included in the provisions of the NHS Litigation Authority at 31 March 2013 in respect of
potential clinical negligence liabilities of the Trust (31 March 2012 £31,083,500).
Contingent liabilities in respect of clinical negligence claims are discussed in note 22.
20
Cash and cash equivalents
At 1 April
Net change in year
At 31 March
Cash at commercial banks and in hand
Cash with the Government
Banking Service
Cash and cash equivalents as in
Statement of cash flows
31 MARCH
2013
31 MARCH
2012
£000
£000
29,604
4,934
34,538
25,001
4,603
29,604
185
86
34,353
29,518
34,538
29,604
21
Contractual Capital Commitments
Commitments under capital expenditure contracts at 31 March 2013 were £16,826,000 (Year to 31 March
2012 £36,931,000). These all relate to property, plant and equipment.
22
Contingent (Liabilities)/Assets
The contingent liabilities at 31 March 2013 were £20,818 (31 March 2012 £26,300). This relates to
outstanding NHS Litigation claims.
The Trust's VAT advisers have submitted a back dated claim for a refund of VAT for catering, private
patients and construction projects. This claim has been made possible following a series of court
judgements that allows NHS Trusts a temporary window in which to make backdated claims. The Trust
has already been able to claim back £221,000 (including interest) and is continuing to pursue the
remaining back claim through its VAT advisors. The maximum remaining claim outstanding at 31st March
2013 amounted to £935,000. The success of this claim will depend on the extent to which this is accepted
by HMRC. The timing of the outcome is uncertain as it is subject to a legal adjudication process.
Page 37
23 Related Party Transactions
Taunton and Somerset NHS Foundation Trust is a body corporate established by order of the Secretary
of State for Health. The Trust is the Corporate Trustee of the charitable funds. The aggregate amount of
the charity's capital and reserves as at the financial year end is £1,830,000 and the deficit for the year is
£176,000. This information is based on unaudited accounts.
Transactions between the Trust and its related parties are reviewed each year and declared below.
During the year none of the Board Members or members of the key management staff or parties related
to them has undertaken any material transactions with Taunton and Somerset NHS Foundation Trust.
The Department of Health is regarded as a related party. During the year Taunton and Somerset NHS
Foundation Trust has had a significant number of material transactions with the Department, and with
other entities for which the Department is regarded as the parent Department. A summary of these
transactions are listed below.
These transactions represent income and expenditure from a range of services and supplies.
Expenditure, for example, includes the purchase of an ambulance service. Income relates to the
commissioning of patient care services, the provision of IT and estates services and the sale of drugs.
Value of transactions with other related parties in 2012/13
Income from
related party
£000
Somerset PCT
Yeovil District Hospital Foundation Trust
South West Strategic Health Authority
Somerset Partnership NHS Foundation Trust
Devon PCT
Charitable Funds
Other related bodies (NHS and Government)
Southwest Pathology Services
Integrated Pathology Partnership
196,001
2,912
11,086
4,209
5,568
843
28,035
385
3,754
252,793
Expenditure
to related
party
£000
371
450
0
1,927
0
18
15,220
2,343
0
20,329
Receivables Payables
owed to
owed by
related party related party
£000
£000
544
754
0
459
572
147
5,068
385
380
8,309
301
86
159
96
0
0
5,472
0
0
6,114
Value of transactions with other related parties in 2011/12
Income from
related party
£000
Somerset PCT
Yeovil District Hospital Foundation Trust
South West Strategic Health Authority
Somerset Partnership NHS Foundation Trust
Devon PCT
Charitable Funds
Other related bodies (NHS and Government)
195,407
3,057
6,813
4,520
6,459
684
21,606
238,546
Page 38
Expenditure
to related
party
£000
434
461
0
2,581
0
12
7,283
10,771
Receivables Payables
owed to
owed by
related party related party
£000
£000
3,427
678
2
871
295
45
3,421
8,739
303
148
153
87
0
5
5,754
6,450
24
Financial Instruments
IFRS 7, IAS 32 and 39, dealing with Financial Instruments, require disclosure of the role that financial
instruments have had during the period in creating or changing the risks an entity faces in undertaking its
activities. The Trust can borrow funds up to its Prudential Borrowing Limit set by Monitor using the risk
rating methodology. The Trust also has the ability to invest surplus cash. The risks resulting from
transactions of this nature are mitigated by the Foundation Trust's treasury and investment policies and
protocols and by the reporting of performance against financial targets to the Foundation Trust regulator,
Monitor.
Liquidity risk
The NHS Trust's net operating costs are incurred under annual service agreements with local Primary
Care Trusts, which are financed from resources voted annually by Parliament. The introduction of
Payment by Results has created an inherent risk of performing at below the planned activity levels
thereby endangering income. The Trust has mitigated this risk through the arrangement of a working
capital facility of £5m with the National Westminster Bank. The Trust currently finances its capital
expenditure from funds made available from cash surpluses generated by the Trust's activities. The PFI
project relating to the Beacon Centre has created liabilities on the Statement of Financial Position that the
Trust is committed to meeting for the duration of the service concession. This liability is subject to annual
inflationary uplift. Similarly, the Trust is committed to the Energy Project which added a leasing liability to
the Trust's SOFP in 2011/12 which increased in 2012/13. The Trust is committed to the payment of this
leasing obligation for the duration of the 12 year lease term. In addition, the future plans for the surgical
re-development (Jubilee Building) could require borrowing. The Trust plans to limit its risk by accessing
borrowing via the Foundation Trust Financing Facility. The approval of major capital projects such as the
Jubilee Building are subject to comprehensive project development processes involving the creation of
separate project boards, continuous scrutiny by the Trust Board and also through the involvement of NHS
partners including the host PCT , Monitor and NHS South of England.
Credit Risk
The risk that the Trust will fail to collect all due income is mitigated by the ongoing strong arrangements
that exist with its host PCT, Somerset PCT, from which most income derives. Other credit risk is provided
for by the continuous processes of reviewing debt management and ensuring that debts that are unlikely
to be collected are appropriately impaired. The Trust reviews all debts over 90 days old to identify specific
impaired debts. More recent debt is also provided for where its collection is thought to be doubtful. The
total impaired debt (per note 16.2) is £354,000.
Interest-Rate Risk
Some of the financial instruments have a fixed interest rate which means the Trust may be exposed to
interest rate risk. If the interest rate moves interest paid could be higher than the market rates, and/or
interest received could be lower than the market rates. Of the financial assets set out in note 25, all are
denominated in sterling.
Investment Risk
The Trust's investments are held either in the National Loans Fund temporary deposits or in a mixture of
short term and medium deposits with the Royal Bank of Scotland, Santander, HBOS, Barclays, Lloyds
TSB or Citibank. The medium term investments run for periods not exceeding 95 days and the short term
investments are normally invested for a term of one to four weeks. The relative liquidity of these deposits
ensures that the Trust mitigates any risk of being unable to fulfil its contractual commitments arising, for
example from a sudden reduction in income. The Trust uses the protocols set out in its Treasury
Management Policy to ensure that credit risk is managed and that only banks with acceptable credit
ratings are included in the panel of approved organisations for investment. The Treasury and Investment
Committee (sub committee to the Board) oversees the management of working capital and the
investment of surplus cash to ensure that the Trust optimises its returns whilst minimising risk.
Foreign Currency Risk
The Trust has negligible foreign currency income or expenditure and exposure to currency risk is not
significant.
Page 39
25
Financial Assets and Liabilities by Category
Assets as per SoFP
At 31 March 2013
Loans and
Receivables
£000
£000
At 31 March 2012
Total
Loans and
Receivables
£000
£000
Total
Trade and other receivables excluding non financial assets
Cash and cash equivalents (at bank and in hand)
Total
Liabilities as per SoFP
6,767
34,538
41,305
6,767
34,538
41,305
At 31 March 2013
Other
Financial
Liabilities
£000
£000
12,000
12,000
6,907
6,907
14,086
14,086
3,834
3,834
11,153
11,153
1,157
1,157
49,137
49,137
Total
Borrowings excluding Finance lease and PFI liabilities
Obligations under PFI contracts
Trade and other payables excluding non financial liabilities
Other financial liabilities
Provisions under contract
Total
26
Fair Values
26.1
Fair Values of financial assets as at 31 March 2013
Non current trade and other receivables excluding non financial assets
Other investments
Other
Total
26.2
Fair values of financial liabilities as at 31 March 2013
Non current trade and other payables excluding non financial liabilities
Obligations under finance leases and PFI schemes
Provisions under contract
Loans
Other
Total
Book Value
£000
7,998
29,604
37,602
At 31 March 2012
Total
Other
Financial
Liabilities
£000
£000
0
0
2,948
2,948
14,789
14,789
2,461
2,461
9,070
9,070
1,117
1,117
30,385
30,385
Fair Value
£000
0
0
41,305
41,305
41,305
41,305
Book Value
£000
Fair Value
£000
82
20,993
1,157
12,000
14,905
49,137
82
20,993
1,157
12,000
14,905
49,137
Financial assets consist of receivables and accrued income. The carrying amounts are determined by their recoverable amount.
Financial liabilities consist of payables, accruals and provisions. The carrying amounts are determined by their invoiced amount.
Page 40
7,998
29,604
37,602
27
Third Party Assets
The Trust held £1,000 cash at bank and in hand at 31 March 2013 (£388.30 at 31 March 2012)
which relates to monies held by the NHS Trust on behalf of patients. This has been excluded from
the cash at bank and in hand figure reported in the accounts.
28
Losses and Special Payments
There were 52 cases of losses and special payments totalling £9,000 (43 cases totalling £6,000
11/12). There were no cases exceeding £100,000 for the current period or prior period.
29
Joint Venture Performance
The Trust holds a 51% share of SPS LLP. This entity is jointly controlled by the Trust, Yeovil and
IPP. The arrangement is treated as a joint venture and is accounted for using equity accounting,
such that 51% of the surplus / deficit made is included in the Trusts SOCI and 51% of the net assets
of the JV are included in the SOFP of the Trust.
2012/13
£000
Profit and loss account
Turnover
Cost of sales
Gross Profit
Operating Expenditure
Loss before tax
11,546
(10,946)
600
(797)
(197)
Trust's share of loss in statement of comprehensive income statement
Statement of Financial Position
Non current assets
Current assets
(100)
0
693
693
Payables: amounts due within one year
Payables: amounts due in greater than one year
890
0
890
Net assets/liabilities
(197)
Share of net assets/(liabilities) recognised in the SOFP
(100)
Page 41
Trust
Name
This Year
Last Year
This Year
End
This Year
Start
Last year
End
Last year
Start
2012/13
2011/12
31 MARCH 2013
1 APRIL 2012
31 MARCH 2012
1 APRIL 2011

Annual Report and Accounts and Quality Account

Transcription

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