annual report and accounts 2015-16 · in 2015-16 the trust saw an 8.7% increase in referrals from...

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Annual Report and Accounts

2015-16

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Kingston Hospital NHS

Foundation Trust

Annual Report and Accounts

2015-16

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

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©2016 Kingston Hospital NHS Foundation Trust

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Introduction from the Chairman and the Chief Executive .............................................................. 6

Performance Report ..................................................................................................................... 8

Overview ..................................................................................................................................... 8

Activity review ............................................................................................................................. 8

Financial review of 2015/16 ....................................................................................................... 10

Strategic Objectives and Supporting Plans .................................................................................. 13

Accountability Report ................................................................................................................ 16

Directors’ Report ....................................................................................................................... 16

Enhanced Quality Governance Reporting .................................................................................... 20

Improvements for patients ......................................................................................................... 22

Listening to patients................................................................................................................... 28

Working with our partners ......................................................................................................... 32

Volunteers ................................................................................................................................. 35

Fundraising ................................................................................................................................ 36

Remuneration Report ................................................................................................................ 40

Staff Report ............................................................................................................................... 46

NHS Foundation Trust Code of Governance ................................................................................ 56

Council of Governors and Membership ....................................................................................... 60

Membership .............................................................................................................................. 63

Monitor regulatory ratings ......................................................................................................... 65

Care Quality Commission (CQC) .................................................................................................. 66

Annual Governance Statement ................................................................................................... 68

Appendices ………………………………………………………………………………………………………………………………. 81

1. Quality Report

2. Sustainability Report

3. Annual Accounts

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Introduction from the Chairman and the Chief Executive

2015-16 has been another busy year for the organisation and a year that both of us look back on

with a great sense of achievement and overwhelming pride in our staff. One of the first things to

recognise is the contribution made by our previous Chief Executive Kate Grimes who sadly had to

retire from Kingston Hospital and the NHS due to ill health.

There are most definitely some clear themes to our achievements and successes this year and the

first one is our continued focus on ensuring that our patients with dementia receive the best

possible care and support. The Trust is now entering Year 3 of its Dementia Strategy and one of the

focuses for this year has been on ‘Active Days and Calm Nights’. Our Dementia Activities room is

now well established and there are activities running every day for patients and their families and

carers to join in with, including chair aerobics; painting; visits from Miko the Pets as Therapy dog;

craft and board games. Our patients can have their hair washed and styled by a visiting hairdresser.

Patients can also eat their lunch together with the support of volunteers in the room. The success of

the activities programme and our Dementia Strategy featured on national BBC coverage of a report

published by the Alzheimer’s Society in January describing the differences in support provided across

the NHS. We’re very proud of the work we are doing. Our major fundraising appeal to raise money

to transform the environment of our elderly care wards and make them more dementia friendly is

well under way and has been backed by the Mayor of Kingston.

In addition to caring for our patients reaching the end of their lives, and supporting them to live as

well as possible, the Hospital’s other big cohort of patients is those just entering the world and in

their first few years of life. Maternity is very much one of our flagship services and the excellent

care provided was reinforced through the publication of the latest maternity patient survey. For the

third survey in a row our new mums rated our services as the best in London, which is a fantastic

achievement for everyone looking after our mums and babies at Kingston. We also spent some time

looking at what would help our youngest patients have a better experience of coming to and staying

in Hospital. In October a new children’s menu was launched, which was developed with the help

and advice of the children we care for and also local schoolchildren. We have also looked at the

experience of patients using services outside of the Paediatrics department and as a result of the

fantastic support of local charity Momentum we have transformed the waiting area in Children’s

A&E, the Royal Eye Unit and the Dental Unit.

Against a backdrop of challenging finances for the NHS in general and increased demand nationally

for emergency services, the Trust successfully concluded an investigation into our financial and A&E

performance by the Foundation Trust regulator Monitor. The investigation was launched in July as a

result of the Trust Board’s decision to set a deficit budget for 2015-16 in order to invest to improve

the quality of experience for our patients, and because the Trust was failing to meet the A&E target,

along with many other Trusts. The investigation was closed in December without need for

regulatory action. Staff and teams worked hard to support the organisation in reducing our deficit

and through this commitment we were able to reduce the predicted deficit from £8.8million to end

the year at £6.9milllion. This is a great achievement in the current challenging NHS environment.

In December we also held our first ever annual staff awards ceremony and celebrated a whole host

of achievements at an amazing evening attended by 150 staff and their supporters. The #TeamKHFT

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awards were hosted by local resident and TV Presenter Angellica Bell and it was such a pleasure to

be a part of the night and see so many of our staff recognised for their achievements.

It goes without saying that one of the most significant events for the Trust during 2015-16 was our

CQC inspection which took place in the second week of January. This involved a huge amount of

preparation and dedication by staff and teams across the whole organisation and we were so

pleased to be able to show the inspection team our absolute commitment to high quality patient

care. We are still waiting for the final report and outcome, but we want to recognise the

contribution that everyone made to the inspection and how honoured and privileged we are to work

with such a fantastic team, including our huge cohort of over 1,000 volunteers.

Thank you to our staff, patients, partners, governors, volunteers and the local community for your

continued support and for helping us to achieve so much during 2015-16.

Sian Bates Ann Radmore

Chairman Chief Executive

23rd May 2016 23rd May 2016

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Performance Report

Overview

Principal activity

Kingston Hospital NHS Foundation Trust is a single site, medium sized Hospital, located within

Kingston-Upon-Thames in South West London. The Trust provides services to approximately 350,000

people locally on behalf of its main commissioners, including Kingston, Richmond, Wandsworth,

Merton and Sutton Clinical Commissioning Groups (CCGs) in South West London and Surrey Downs

CCG (East Elmbridge locality) in Surrey.

The hospital is on the site of the former Kingston Union Workhouse, built in 1839 as a result of the

Poor Law Amendment Act 1834. An infirmary was built on the site of what is now Regent Wing in

1843. In 1948, when the NHS was launched, the entire former workhouse site was given over to the

hospital. The Trust was licensed as a NHS Foundation Trust, a not-for-profit, public benefit

corporation authorised under the National Health Service Act 2006 to provide goods and services for

the purposes of the health service in England, with effect from 1 May 2013.

The Trust has some 520 beds and directly employs around 2,900 staff, with another 300 staff employed by contractors working on behalf of the Trust. In the last year the Trust saw over 113,437 patients in A&E, undertook 388,747 outpatient appointments and cared for 71,898 admitted patients (this included Maternity admissions). The Trust’s maternity unit delivered 5,800 babies.

As well as delivering services from the main hospital base, the Trust delivers ambulatory services at a

range of community locations in partnership with GPs and community providers.

The Trust’s clinicians provide and/or support care in outpatient and day surgery facilities at a

number of community locations including:

Queen Mary's Hospital, Roehampton,

Teddington Memorial Hospital

Molesey Hospital

Cobham Day Surgery Unit

Emberbrook Community Centre

Raynes Park Health Centre

Surbiton Health Centre

Ebbisham Centre, Epsom

Glenlyn Medical Centre

Epsom Cottage Hospital

Leatherhead Community Hospital

The Trust has strong links with tertiary and specialist hospitals, particularly St George’s University

Hospitals NHS Foundation Trust and The Royal Marsden Hospital NHS Foundation Trust who jointly

provide cancer services on the Kingston Hospital site in the Sir William Rous Unit. The Trust has close

links with Kingston University and St George's Medical School, and jointly runs the Elective

Orthopaedic Centre at Epsom Hospital in partnership with St George’s University Hospitals NHS

Foundation Trust, Croydon Health Services NHS Trust and Epsom and St Helier University Hospitals

NHS Trust.

Activity review

During 2015-16, the Trust continued to provide a range of services to its catchment area, including:

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A full Emergency service

Elective and Emergency services in Surgery and Medicine

Women’s and Children’s services

Therapies, Diagnostics and Pharmacy services

In 2015-16 the Trust saw an 8.7% increase in referrals from GPs compared to referrals in 2014-15.

In terms of activity, the Trust’s elective workload in 2015-16 was 1.1% lower than that of 2014-15.

Approximately 86.4% of elective activity was undertaken on a day case basis.

The number of births at the hospital during 2015-16 remained similar to that of the previous year

with a total of 5,800 births. Deliveries have been largely stable, as our unit is at capacity.

Outpatient activity in general has grown year on year. This is due to demographic growth and

increasing numbers of frail elderly within our catchment, and in recent years is also due to increases

in local market share. There are also small effects of changes in counting, such as capture and

inclusion of community midwifery work. The spike in outpatient activity in 2011/12 was due to non-

recurrent 18 week work.

Planned admissions have increased due to the increase in outpatients. Alongside this growth,

however, there has also been progressive shift of elective inpatients to a daycase setting, and

daycases to outpatient procedure.

Demand management initiatives such as walk-in centres have helped to keep A&E attendances

relatively stable, although acuity of the average A&E attendance at KHFT has increased. Fluctuations

in attendances year to year can be due to the severity of the winter, and coverage of pressures on

A&E departments in the national press. The number of emergency admissions has remained

consistent from 2010-2015, as we have worked hard to admit patients only when necessary.

However, admissions increased in 2015/16 due to the new PAU (Paediatrics Admission Unit), a

shortstay paediatric facility which has reduced the numbers of paediatric A&E attendances and

longer inpatient admissions.

Elective Activity

2010-11 2011-12 2012-3 2013-4 2014-15 2015-16

(Spells)* (Spells)* (Spells)* (Spells)* (Spells)* (Spells)*

Daycase 22,017 22,298 22,204 23,521 24,756 24,592

Inpatients 4,442 4,546 4,300 4,328 4,027 3,866

Births 5,929 5,914 5,985 5,863 5,866 5,800

Non Elective Activity

2010-11 2011-12 2012-13 2013-14 2014-15 2015-16

ED Attendances 109,720 113,021 113,360 110,384 110,473 113,437

Emergency Admissions

21,868 21,572 21,076 21,488 21,054 26,602

A&E 4 hour target

98.1% 97.1% 96.4% 95.7% 94.4% 92.1%

Outpatient Attendances

323,018 342,360 332,932 343,488 369,859 388, 747

*Excludes attendances at the Wolverton Centre

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Number of patients on the waiting list

Mar-11 Mar-12 Mar-13 Mar-14 Mar-15 Mar-16

18 week Pathways

16,166 11,474 12,575 14,173 15,093 15,351

Outpatient 13,340 8,889 10,442 11,816 12,674 13,079

Inpatient 2,826 2,602 2,769 2,810 2,419 2,272

Key Issues and Risks to the Delivery of Objectives With regard to the principle risks to compliance with the NHS Foundation Trust Condition 4 (FT Governance) and actions identified to mitigate these risks during the course of the year, Monitor opened an investigation into Kingston Hospital NHS Foundation Trust in June 2015 due to concerns about financial sustainability and performance, the Trust having breached the Accident and Emergency (A&E) four-hour wait target for three consecutive quarters. In December 2015, Monitor closed the investigation without formal regulatory action, which was replaced by informal monitoring and support to ensure ongoing sustainability in both finance and performance. The Trust recognised that turnover within the Board presented a potential risk to the organisation’s ability to address sustainability and performance issues and moved quickly to address turbulence in Board membership during 2015/16. The posts of Chief Executive, Chief Operating Officer and Director of Workforce were covered by interim appointments at points during the year, as detailed in the Remuneration Report. The Trust is managing the financial risks through close control of finances, minimising expenditure where possible and ensuring proactive discussions continue to take place with commissioners. Efficiencies identified by Lord Carter are being evaluated, and the Trust has taken a realistic and evidence based approach to setting cost improvement plan (CIP) levels for 2016/17. A recovery and transformation plan to enable the Trust to meet the A&E standard was developed with expert support, including from ECIP, and the Trust continues to engage with external partners to find ways to reduce delayed transfers of care. Reports on the impact of these actions have been made to Monitor (now NHS Improvement) on a monthly basis. Principal risks to compliance with Condition 4 of the Monitor licence around governance were tested during the year through self-assessment against the Monitor Licence and through an independent assessment against Monitor’s Well Led framework for governance. Potential risks to compliance were assessed regularly through the Board Assurance Framework and in work to develop the Quarterly submissions to Monitor, which have been monitored by the Finance & Investment Committee in months in which Board meetings have not taken place. Performance Analysis The Board receives performance reports at each formal Board meeting, each Director presenting reports on achievement of targets in relation to their own portfolios in reports on Clinical Quality, Operational Performance, Finance and Workforce. Performance reports are also discussed at Board committee meetings where a ‘deep dive’ approach is taken to gaining additional assurance on any areas of concern.

Financial review of 2015/16

Financial Performance The Trust achieved a financial position of a £6.9m deficit for the year ended 31 March 2016 before impairments and revaluations. This was in line with the control total agreed with Monitor which took into account the impact of the junior doctors’ strikes. This was a significant improvement on the original budget of an £8.8m deficit. A Financial Sustainability Risk Rating (FSRR) of 2 was achieved for the year, in line with plan.

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Revenue In the year to 31st March 2016, the Trust received income of £233.2m. This represents an overall increase of 3.3% compared to the income received for the 31st March 2015. This is analysed below:

The Trust received Patient Care Income of £205.9m. This represents an overall increase of 4.7% compared to the year to 31st March 2015 and is driven largely by outpatient activity, non-elective and emergency activity, and high cost drugs-related income. Approximately 88.3% of total revenue was derived from patient care in 2015/16 compared to 87.1% in 2014/15.

Expenditure Total costs for the year ended 31st March 2016 were £247.4m compared to £229.3m for the 12 months to 31st March 2015, comprised as follows:

Total costs increased by £18.1m of which £13.1m related to staff costs. This included inflation, grade drift and pensions. This also included investments required in order to ensure safety and quality, for example, in doctors in A&E and in midwives to move towards midwife to birth ratios closer to guidelines. Running costs (or non-pay costs) increased by £4.6m, driven by inflation, costs related to the increased activity levels, overseas recruitment costs and the costs of the patient administration system for which the costs had previously been funded nationally. Capital The Trust delivered a capital programme of £10.5m or 85% of the original plan of £12.3m. The plan was split into four areas:

Expenditure related to the Estates strategy (£5.8m)

Maintaining and updating the estate (£2.1m)

Investment in IT infrastructure and systems (£3.5m)

Replacing clinical equipment (£0.9m)

£m

Year to

31st

March

2016

Year to

31st

March

2015

Staff Costs 148.3 135.2

Running Costs (Excluding Staff) 92.6 88.0

Finance Costs (Including PFI) 3.5 3.2

Public Dividend Capital dividend payable to HM Treasury 3.0 2.9

Total Expenditure 247.4 229.3

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Of the Estates strategy expenditure, £3.4m related to window replacement in the Esher Wing, and £1.5m to the Outpatients refurbishment project. Total expenditure was below plan as a result of delays to the Outpatients Project, which is now expected to complete in 2016/17. The Estates Strategy is largely funded by a loan from the Department of Health. A facility of £10m had been agreed during October 2014, from which £3.4m had been drawn down prior to the start of the financial year, the remaining £6.6m being drawn down during the 2015/16 financial year. Expenditure on Estates maintenance of £1.4m included £0.6m in respect of pipework replacement and £0.4m relating to refurbishment of lifts. Revaluation and impairment The Trust’s land and buildings were revalued as at 31st March 2016. There were reductions in the value of certain buildings totalling £4.4m and in the valuation of land totalling £7.7m, resulting in a total impairment of £12.1m. £7.3m of this was charged to operating expenses and £4.8m to the Revaluation Reserve. Offsetting the latter, there were increases in building values of £9.1m, resulting in an overall net reduction in asset values of £3.0m. Cash The Trust’s cash holding decreased from £6.4m at 31st March 2015 to £4.4m at 31st March 2016. The Trust continues to have access to a working capital facility of £6.0m, which it was not necessary to utilise at any point in the year. Cost Improvement Plans (CIPs) The Trust successfully delivered £8m (89%) of its £9m efficiency target in 2015/16. Over the past few years, the Trust has consistently delivered 3.5% to 4.5% efficiencies. The task to identify and deliver further savings becomes more challenging each year. Schemes that were not delivered or only partially delivered include reducing winter escalation capacity (£0.3m), and length-of-stay reduction (£0.2m). 2016/17 Future Plans For 2016/17 the Trust is planning an underlying deficit budget of £4.2m. If the Trust takes into account the proposed injection of £8.1m from the Sustainability and Transformation Fund (STF), it would result in a planned surplus position of £3.9m. This combined with other metrics gives a Financial Sustainability Risk Rating (FSRR) of 3. Delivery of this position is based upon a number of assumptions which have been clearly stated in the Trust’s Annual Plan submission to NHS Improvement. For example, it has been assumed that there will be no adverse impact of the junior doctors’ industrial action or of adopting any new contract and that the STF will be received in full. The Trust will start 2016/17 with a cash balance of £4.4m, and is forecasting a closing cash balance at 31st March 2017 of £1.9m. The Trust is planning capital expenditure of £9.2m for 2016/17. This is significantly lower than the £12.3m plan in the current year but 2015/16 included expenditure on an Estates Strategy including new windows (£3m) and the refurbishment of Vera Brown House (£2.3m) which was in part funded by a loan. Going Concern 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, they continue to adopt the Going Concern basis in preparing the accounts.

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Forward Plan The financial context remains challenging, given the forecast underlying deficit for 2016/17. The Trust will continue to focus on the delivery of its recovery plan and the development of plans to support longer term sustainability. As well as seeking to maximise efficiency and productivity, the Trust is collaborating with local partners across South West London to transform service delivery across organisational boundaries and ensure limited resources are used to deliver the best value for patients. The external environment is complex with the emergence of a number of collaborations and new models of commissioning and delivery including outcomes based commissioning and Accountable Care Organisations. The Trust continues to work through the implications of these developments to ensure that it is well placed to work as a true partner within the wider system; to mitigate the risks and take advantage of the opportunities that arise from these new mechanisms. The Lord Carter report into productivity in the NHS has identified opportunities for improving productivity across all trusts. These are being validated and assessed for inclusion in Trust plans. Statutory Responsibilities Incident reporting has increased in general. The number of incidents reportable to the Health &

Safety Executive (HSE) remains low. The Health & Safety Executive attended the hospital in April

2015, the focus of the inspection was on the management of sharps. Some verbal

recommendations were made, however, there were no breaches, written notifications, or

prohibitions issued.

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 projections, to ensure that this organisation’s obligations under the Climate

Change Act and the Adaptation Reporting requirements are complied with.

Strategic Objectives and Supporting Plans A summary of progress towards achievement of strategic objectives is outlined below:

Strategic Objective 1 To ensure that all care is rated amongst the top 20% nationally for patient safety, clinical outcomes and patient experience

The Trust prepared for the Care Quality Commission (CQC) inspection which was undertaken in January 2016. It is currently awaiting the inspection report; once the report is published the Trust will implement a plan in response to the findings.

A range of initiatives were implemented to support the achievement of the London Quality Standards (LQS) including the delivery of 7-day working.

The Trust performed well against most operational targets. In particular, it had excellent 18-week referral to treatment performance and low levels of hospital acquired infections. Performance against cancer access standards improved significantly over the year. Accident and Emergency (A&E) waiting times were below target, a comprehensive action plan improved performance in the second half of the year.

The Trust implemented Year 2 of its Dementia Strategy, including improvements to the ward environment, extending the activities programme to enable reminiscence therapy on all wards and the identification and monitoring of key harm levels (for example, falls and pressure ulcers) in patients with dementia as a precursor to developing targeted safety improvement programmes. The Trust has been recognised for its work on dementia and was

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highlighted as a positive case study of dementia care in the Alzheimer’s Society report ‘Fix Dementia Care’ and featured in national BBC coverage. The results of the PLACE Inspection highlighted room for improvement in relation to the environment for patients and this will be a key focus for 2016/17.

KHFT progressed toward paper light status through the completion of the roll out of electronic prescribing, implementation of device integration in some areas and increasing electronic links with GPs systems through DOCMAN.

Some progress was made against the improvement plan for patient administration in 2015/16, particularly in relation to embedding the patient pathway coordinator model in each service line. However, overall progress fell below expectations. This will be a key focus area for 2016/17.

The Trust has developed a Cancer Strategy with a clear vision for how cancer services will be led. Pathway redesign for specific tumour groups has been completed and implementation has commenced.

Year 2 of the Estates Strategy was implemented to address key quality of care issues associated with the environment. Works completed include the replacement of the windows and associated external works to Esher Wing to improve the environment for both patients and staff. Refurbishment of the main outpatients department has not progressed as quickly as planned and completion is now a priority.

Strategic Objective 2

Strategic Objective 2 To have a committed, skilled and highly engaged workforce who feel valued, supported and developed and who work together to care for our patients

Investments made over the year had a positive impact on recruitment and retention with a significant reduction in vacancy rates from 14% to 9% between April and December 2015 and a small reduction in turnover.

This investment included international recruitment campaigns, more practice development nurses to support new recruits, the Kingston Positivity Programme and training on a coaching approach to 1:1s and appraisals.

A continued focus on investment in this strategic objective is required for 2016-17.

Initial indications from the Staff Survey for 2016 suggest an improved position for the Trust in terms of achieving this objective. However, there is more to do throughout 2016-17.

Strategic Objective 3 To work creatively with our partners (NHS, commercial, community and voluntary) to consolidate and develop sustainable high quality care as part of a thriving health economy for the future

The Trust worked collaboratively with partners across South West London, as part of the Acute Provider Collaborative and the wider South West London and Surrey Downs Healthcare Partnership. It developed plans to support clinical and financial sustainability across the sector.

The Trust worked in partnership with Kingston CCG and local providers to develop a new integrated model of care for adults requiring care and support (Kingston Co-ordinated Care) and supported the live testing of the model.

The Trust was selected by Richmond CCG as one of four Most Capable Providers to develop proposals to provide out of hospital services through OBC. The four providers submitted a response to the Invitation to Submit Detailed Proposals in January 2016 and are now developing a programme of work to transition to the new model including plans for a Contractual Joint Venture with the partners.

In July 2015 the Trust agreed to become part of an Accountable Clinical Network for Cancer Services in West London to improve the integration of services across the entire pathway.

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Delivery against year 2 of the volunteering strategy progressed well and the Trust is now supported by 1,000 volunteers compared with 350 before implementation of the strategy.

Strategic Objective 4 To deliver sustainable, well managed, value for money services

The Trust commissioned an independent governance review based on the Monitor Well-Led Framework. This concluded that the Trust is well led and that the governance processes and structures are sound and working well including those relating to performance management. Some areas of outstanding practice and many areas of good practice were identified. The review agreed that patient safety and quality is the Trust’s priority.

2015-16 was a challenging year financially for the Trust. It was forecasting a full-year deficit of £6.4m and finished the year with £6.9m due to the unforeseen impact of junior doctors’ strikes. However, the final deficit is an improvement of £1.9m on the budget set at the beginning of the year. This improvement is a result of a focused recovery plan.

The Trust embedded and strengthened the effective functioning of service line management across the organisation, with 14 of the 19 service lines now accredited.

Cost Improvement Plan (CIP) for 2016-17 Although challenging, the Trust has identified cost improvement plans (CIPs) for 2016-17. As in

previous years, a robust process has been followed, with each Service Line receiving benchmarking

data to inform opportunities and then developing their CIPs with support and challenge from the

Divisional Director and Associate Director. Divisional plans are then reviewed by executive directors

to provide a further round of support and challenge, prior to approval of the programme. Alongside

this, a range of cross-cutting CIPs are identified and worked up with a dedicated senior management

lead and executive sponsor. This process has enabled the identification of CIPs totalling £9.2m

against a target of £9.9m to date, with further work planned to finalise the programme.

The breakdown for the 2016-17 CIP programme by type and category is provided in the table below.

Identified by Category Identified (£m)

% identified of total target

Pay CIP 3.8 38%

Non-pay CIP 2.1 21%

Total cost CIPs 5.9 60%

Net Income – Patient Care

2.6 26%

Net Income – Other 0.7 2%

Total income CIPs 3.3 28%

Grand Total 9.2 93%

Summary Target (£m)

Identified (£m)

Variance (£m)

Identified (%)

Total identified to date 9.9 9.2 (0.7) 93%

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Accountability Report

Directors’ Report

The Directors present their annual report together with the audited financial statements for Kingston Hospital NHS Foundation Trust (the Trust) for the period 1 April 2015 to 31 March 2016. The Directors’ Report incorporates the Chairman’s and Chief Executive’s statements and together with the management commentary and business review gives an analysis of the development and performance of the Trust over the year and the vision for the future. Board of Directors As can be seen from the directors’ biographies below and from our compliance with the requirements of the Monitor Code of Governance, the Board of Directors (the Board) has an appropriate composition of skills and depth of experience to lead the Trust. The Directors who held office during the year were: Non-Executive Directors (all voting members) Sian Bates Chairman Appointed September 2013, reappointed with effect from September 2016 to 31 August 2019 Sian was appointed as Chairman on 1 September 2013. Sian was Chair of NHS South West London between 2011 and March 2013 and was Chair of Richmond and Twickenham Primary Care Trust from 2001. She has also been a Governor of Richmond Adult Community College and a consultant specialising in Organisational Development and Human Resources. Sian started her career in the Civil Service and established and held Executive roles with AZTEC, the Training and Enterprise Council for South West London, for 10 years. Martin Grazier Non-Executive Director Appointed February 2014, end of tenure February 2017 Martin joined the Trust Board on 1 February 2014 as a Non-Executive Director. Martin is a former partner in PricewaterhouseCoopers with extensive experience of working at Board level in the global energy sectors. Martin’s earlier career involved senior management roles in Shell International. Martin has led and managed large projects on strategic change and transformation, business start-ups and turnarounds, mergers and acquisitions, and corporate finance in Europe, Asia and Africa. Sylvia Hamilton Non-Executive Director Appointed January 2016, end of tenure January 2019 Sylvia joined the Trust Board on 18 January 2016 as a Non-Executive Director. She is an experienced senior Human Resources (HR) professional. Most recently she served for 9 years as Group HR Director at Grosvenor, the International Property and Fund Management business. Prior to that she was an HR Director at EY, the accountancy firm, where she also held responsibility for graduate recruitment. Sylvia worked at BT from graduate entry to senior HR positions; she also held operational roles, such as in customer service, managing large groups of people. Michael Jennings Non-Executive Director/Senior Independent Director Appointed June 2010, resigned with effect from 31 March 2016 Michael joined the Trust Board on 1 June 2010 as a Non-Executive Director. Until 2009 he acted as Deputy Chief Executive at Surrey County Council having held various director posts at the authority with responsibility for corporate planning, emergency management, policy, performance,

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joint/partnership working (including health, police, business, and the voluntary sector), external affairs, and governance and health scrutiny. Prior to that he worked in strategy, planning, finance, and management posts in local government in London. He is a member of the Government's Advisory Panel on Public Sector Information.

Joan Mulcahy

Non-Executive Director Appointed January 2011, end of tenure January 2018 Joan joined the Trust Board on 13 January 2011 as a Non-Executive Director. She is a Management Consultant, a professionally qualified accountant and an experienced Board level Director with significant experience in the Banking industry. Previously she worked for Allied Irish Bank Group where she held a variety of roles, culminating as Chief Operating Officer and Board Director of AIB Group (UK) PLC. She currently undertakes a number of non-executive roles in various strategic bodies. Dr Chris Streather Non-Executive Director Appointed February 2014, end of tenure February 2017 Chris joined the Trust Board on 1 February 2014 as a Non-Executive Director. He is a renal physician by training and worked at Brighton, at Kings, as a National Kidney Research Foundation Fellow, and Cambridge, before being appointed to St George’s Hospital as a Consultant in 1997, from where he set up the Kingston renal outreach service. He became Medical Director in 2004, later Director of Strategy and worked on the National Physicians Assistant pilot, the RCP Acute Medicine Task Force and Lord Ara Darzi’s Framework for Action. In 2008 he was the London Clinical Director as London’s Stroke services were redesigned and worked on the Primary and Community Care Advisory Board of the NHS Next Stage Review. He is Deputy Chair of the London Leading for Health Partnership and a member of Lord Ara Darzi’s Health Commission. From 2009-12 he was the first CEO of South London Healthcare, before becoming the Managing Director of the Health Innovation Network. Chris is currently Chief Medical Officer at HCA International. Jacqueline Unsworth Non-Executive Director Appointed March 2011, end of tenure March 2018 Jacqueline joined the Trust Board on 21 March 2011 as a Non-Executive Director. She was formerly the Vice Chair and Non-Executive Director of Hounslow PCT and a Trustee of the charity Family Action. Jacqueline is a retail strategy specialist and has worked as a Board level consultant with a range of retail brands including John Lewis and Woolworths. Jacqueline has also been a Director at Piper Trust Ltd and has worked in strategic planning roles for Storehouse PLC and Abbey National. Candace Imison Non-Executive Director/Deputy Chair Appointed December 2009, resigned with effect from 31 August 2015 Candace was appointed Non-Executive Director on 1 December 2009. Candace has had a long career in the NHS where she has held a number of Board level and senior management roles, including Director of Healthcare Systems at the Nuffield Trust, senior strategy advisor at the Department of Health and Deputy Director of Policy at The King’s Fund.

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Executive Directors Ann Radmore Chief Executive Appointed September 2015 as Interim Chief Executive and May 2016 as Chief Executive Ann has worked in the NHS for over 30 years and started her career as a management trainee. Before joining Kingston Hospital she was the Director of the national Better Care Fund programme at NHS England and was previously Chief Executive of the London Ambulance Service. Ann was also Chief Executive of NHS South West London having been Chief Executive of NHS Wandsworth. Ann led the London-wide implementation of the ground breaking stroke and cardiovascular models – which significantly improved outcomes for patients through specialist units. Rachel Benton Director of Strategic Development and Acting Chief Executive from 16 July – 14 September 2015 Appointed March 2010 Rachel joined the Trust on 1 March 2010. Rachel has worked in the NHS since 1990 in a variety of roles covering general management, strategy, planning and business development. Before joining Kingston Hospital Rachel headed up the planning and business development function for Imperial College Healthcare. Rachel is a graduate with an MSc in Health Services Management. Duncan Burton Director of Nursing & Patient Experience, Director of Infection Prevention and Control and Acting Chief Operating Officer from 16 July to 31 August 2015 Appointed February 2013 Duncan joined the Trust as Director of Nursing & Patient Experience on 4 February 2013. Prior to joining the Trust, Duncan was Deputy Chief Nurse at University College London (UCL) Hospitals and was responsible for a number of corporate areas on behalf of the Chief Nurse. Duncan has held a number of posts since joining UCL Hospitals in 2002, including Charge Nurse in Acute Admissions, Modern Matron for Infection & Pathology and Divisional Senior Nurse Emergency Services, and Head of Nursing, Medicine Board. In 2009 Duncan was awarded a place on the NHS London Aspiring Nurse Directors leadership programme. Eileen Doyle Interim Chief Operating Officer Appointed August 2015 left April 2016 Eileen has worked in the NHS for over 20 years, mostly in the acute sector. She started as a junior operational manager and has worked in a range of hospitals from large tertiary trauma centres to smaller district general and integrated organisations. She has worked at Board level for many years and has a strong track record in helping organisations improve their operational performance and patient experience. Jo Farrar Director of Finance Appointed April 2015 Jo joined the Trust on 1 April 2015 from Homerton University Hospital NHS Foundation Trust where he had been the Director of Finance since March 2010. Previously he was the Interim Director of Finance at the Oxford Radcliffe Hospitals NHS Trust, acting Chief Executive of NHS London's Provider Agency, and Head of Compliance at Monitor. Jo trained as a chartered accountant at KPMG where he gained experience of a number of mergers and acquisitions and as a senior member of the Transaction Services Team.

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Anne Robson Interim Director of Workforce Appointed March 2016 Anne Robson is an experienced Human Resources Director with many years of Board level experience in both the Public and Private sector. She held senior positions with organisations such as Sodexo, Adecco, Care UK, Forte Hotels and The Rank Group before becoming an Interim HR Director. Her interim career spans 9 years and has enabled her to bring her extensive private sector experience to employers in the health, housing and not for profit sectors. Jane Wilson Medical Director Appointed August 2009 Jane was appointed Medical Director on 3 August 2009. Jane has over 20 years’ experience at Kingston Hospital as a Consultant Obstetrician and Gynaecologist, and has held a number of leadership roles within the Trust. In a clinical management role in the Women and Child Health Division she led the expansion of the maternity service to a capacity of more than 5,000 deliveries. She has an interest in education and held the role of Director of Medical Education from 2002 to 2009, overseeing implementation of the national changes in the structure of junior doctors training. As Medical Director she shares responsibility for Quality with Duncan Burton, who leads on Patient Safety. Kate Grimes Chief Executive Appointed December 2008, retired in March 2016 Kate joined Kingston Hospital NHS Foundation Trust as Chief Executive on 10 December 2008. Graduating in Biology, her first job in the NHS was as a porter, followed by various roles managing a range of clinical and non-clinical services. After gaining a distinction in her Masters in Health Services Management, Kate specialised in service improvement and redesigning services with patients, managing a major change programme at King’s College Hospital which pioneered new techniques in service design and delivery. In 2002, Kate joined the South East London Strategic Health Authority as Director of Development before being appointed Deputy Chief Executive in 2004. Kate was appointed Chief Executive of Queen Mary’s Sidcup in October 2005. Kate joined Kingston in 2008 and successfully led Kingston Hospital to achieving Foundation Trust status in May 2013. Dr Charles Bruce Deputy Chief Executive Interim from October 2014. Appointed as Deputy Chief Executive in February 2015 and left the Trust in June 2015. Dr Charles Bruce joined Kingston Hospital as Interim Deputy Chief Executive in October 2014. He is a Physician by background and has a wealth of experience in senior executive roles in the NHS. Prior to joining Kingston Hospital, he was Managing Director at Health Education North West London and before taking up that role, was the Director of Operations and then Deputy Chief Executive at the Royal Free, London. Charles was the Director and Medical Lead for the National Clinical Governance Support Team and co-authored the Department of Health’s Integrated Governance handbook in 2006. He has a breadth of experience in clinical governance and clinical service development acquired at the University Hospital Birmingham NHS Foundation Trust and planning patient centred models of care at a new hospital build at the Royal Infirmary of Edinburgh, and as a management consultant at Booz Allen Hamilton. Charles studied medicine at Kings College London.

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Terry Roberts Director of Workforce (non-voting) Appointed June 2014 left the Trust in February 2016

Prior to joining Kingston Hospital in June 2014, Terry was Associate Director of HR at Barts Health and was responsible developing and implementing the HR strategy for the merger and implementing a business focused leading edge HR function. Terry has held positions as Deputy Director of HR at Barts and London Trust and Ealing Hospital and also worked at the Department of Health as a National HR Adviser for Trust Boards across the country. Terry has a Master’s Degree in Human Resource Management and has completed the Kings Fund Top Manager Programme. Other Changes to the Board Derek Macallan joined the Board as an Associate Non-Executive Director in January 2015 for a period of six months and left the Trust in July 2015. Nicola Hunt, Director of Productivity, Innovation & Improvement Nicola Hunt was appointed in February 2013 and left the Trust in June 2015. Register of Directors’ Interests

The Register of Directors’ Interests is available for inspection during normal office hours at the Chief

Executive’s office and is published on the Trust’s website.

At the time of writing the report, so far as all directors are aware, there is no relevant audit information of which the company's auditor is unaware, and they have taken all the steps that are necessary as a director in order to make themselves aware of any relevant audit information and to establish that the Trust’s auditor is aware of that information. Declarations The Better Payment Practice Code requires the Trust to aim to pay all undisputed Non-NHS invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later. During 2015-16 the Trust paid 37% of non-NHS invoices within 30 days of receipt. The Trust has complied with the cost allocation and charging guidance issued by HM Treasury. The Trust has met the income disclosures as required by section 43(2A) of the NHS Act 2006. Enhanced Quality Governance Reporting

NHS Improvement and the Care Quality Commission (CQC) now share an aligned view of a well-led organisation. This is reflected in the Well-Led Framework for Governance issued by Monitor as the point of reference for NHS foundation trusts and replaces the Quality Governance Framework (QGF) and the Board Governance Assurance Framework (BGAF), which are now effectively incorporated within the Framework. In 2015-16 the Trust commissioned an independent review against the Well-Led framework which reported against four key domains: strategy and planning; capability and culture; process and structures; and measurement. The review tested the Board’s self-assessment against the Well-Led framework, which had been completed towards the end of the financial year 2014-15, highlighted areas of good practice and identified areas for improvement. In November 2015 the Board also carried out a self-assessment exercise in preparation for the inspection carried out by the CQC in January 2016.

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In summary, the Well-Led review resulted in the following conclusions about the Trust’s performance, internal control and board assurance framework. A brief overview of actions to improve the governance of quality in response to recommendations from the Well-Led review report is also shown under each of the four key domains. Strategy and planning – There is a clear Vision which, together with the Trust’s Values, are communicated across the Trust and well understood by the staff. The Trust’s strategic objectives are also clear and there is a five year Quality Strategy with priorities and goals. There is a clear structured planning process with good engagement with stakeholders and a process for involving clinicians in the development of services. The Board has reconfirmed for 2016-17 a strategic objective to work creatively with partners (NHS, commercial and community/voluntary) to consolidate and develop sustainable high quality care as part of a thriving health economy for the future. The Well-Led review report acknowledged this as a necessary step under this domain. The report also recommended a review of the remit of the Compliance & Risk Committee and as a result the Trust has revised its Risk Management Strategy, placing management of risk alongside management of performance in the remit of the Executive Management Committee. The Risk Management Strategy is described in more detail in the Annual Governance Statement. Capability and culture - The independent Well-Led review judged that the Board has the skills and capability necessary to lead the Trust and that this was evidenced in 2015-16 by the way in which the Board lead the Trust and maintained stability through a period of significant change on the Board during 2015-16. The Board has good development plans in place for the Board and for the Council of Governors, as well as effective selection, induction and succession planning for the Board and a good appraisal system with personal development plans. The report highlighted a strong quality culture led by the Board, and that leaders throughout the organisation prioritise safe, high quality, compassionate care. The Board has appointed substantive staff to the two Director positions that were held by interims when the review was undertaken, appointing a Chief Operating Officer in April 2016 and Chief Executive in May 2016. The Board acknowledges that staff morale needs to improve and has continued in 2016-17 to work towards achieving a strategic objective to have a committed, skilled and highly engaged workforce who feel valued, supported and developed, and who work together to care for our patients. The Workforce Committee continues to report directly to the Board in order to maintain clear sight of progress in achieving workforce objectives at Board level. Process and structures - The report concluded that the Trust has an effective unitary Board with a clear Committee structure and valuable engagement with the Council of Governors. The Audit Committee was praised in particular and it was observed that quality issues have good coverage at Board meetings and the Board Assurance is used as a dynamic working document. The Trust’s incident reporting system was considered to be effective, with good feedback and learning built into it, and patient experience is taken seriously. Whilst there are positive relationships with external stakeholders and the Trust is a key player in collaborative projects in the local health economy, the Board’s actions towards improving staff morale are also relevant to this domain. Measurement - The Well-Led review concluded that the Board receives comprehensive performance reports and scrutinises the information by delving deeper into the information. Financial reporting is detailed and transparent and performance information is used to hold services to account where necessary. The Board has planned a stocktake of management arrangements and supporting infrastructure (both corporate and clinical administration services) for service line management in 2016-17 to identify any areas of potential refinement or improvement. The IT Strategy is to be refreshed to describe the use and development of the electronic patient record and to plan the roll out for further implementation. The Board also plans to develop a strategy for access and systemic review of clinical information from both DISCO and CHKS.

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Further detail on the Trust’s approach to quality governance and to quality are provided in the annual governance statement and in the quality report. A summary of the outcome of the Well-Led review is available from the Trust’s website. Improvements for patients Kingston Hospital one of CHKS Top Hospitals Kingston Hospital was named as one of the CHKS Top 40 Hospitals for 2015. Kingston is the only Trust to feature in the list every year for the last 15 years and this is down to the commitment of our staff to provide high quality care for our patients. The Top Hospitals award is one of several awards that are part of the CHKS Top Hospitals programme. First Ever Breaking the Cycle Week Kingston Hospital completed the first ever ‘Breaking the Cycle Week’ in April 2015. The week was aimed at improving the patient journey through the hospital, providing a step-change in performance and providing a better experience for patients. Throughout the week the Trust worked differently, tested new ideas and worked with local partners such as the local authority and other community providers to keep ‘patient flow’ as smooth as possible. Some of the initiatives introduced during the week were consultant reviews of all adult acute inpatients twice a day, quicker turnaround on some test results, additional porters to facilitate patient moves, senior managers being informed of blockages in discharges, releasing senior nursing and operational staff from regular meetings to focus on the week and all wards being adopted by a member of the executive management team to support during the week. The Trust is working on implementing ideas that came out of this successful week. National Patient Safety Award for End of Life Care Kingston Hospital was shortlisted for a national patient safety award for End of Life Care in 2015. This reflects hard work the Trust has undertaken, led by the Hospital’s Palliative Care Team, in developing models for the care of dying patients. This includes the Trust Principles of Care for Dying Patients and accompanying Individual Nursing Care Plan. The work undertaken with clinical teams helps to identify patients approaching the end of life, support them to have conversations about wishes and preferences and to engage in advance care planning, including creation of Co-ordinate my Care records - an electronic palliative care patient record. In addition to this, Kingston is the first Trust in the country to develop a policy that allows a copy of the DNACPR form to go home with the patient and remain valid for up to 7 days until reviewed in the community. The Trust has also developed its education provision to support generalists provide better end of life care, with development of new and innovative models of education delivery. Pressure Ulcer Strategy The Trust has made significant progress in reducing the number of patients developing Pressure ulcers. The impact of the work has been significant with an overall reduction in grade 2 pressure ulcers by 42.3%, and no grade 4 pressure ulcers reported in 2015 -16, compared to 3 in 2014 – 15. To mark international Stop the Pressure day in November we launched our first ever Pressure Ulcer Strategy. Boards detailing our strategy for the next 3 years are displayed on all inpatient wards and A&E. This strategy aims to reduce further our pressure ulcer incidence by 10% by promoting a multi-disciplinary approach to pressure ulcer prevention. The strategy sets goals to improve health promotion with patients and also documentation and communication within the Trust and with our community colleagues.

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Emergency Services Division A&E, AAU, Elderly Care, Cardiology, Respiratory Medicine, Gastroenterology and Endoscopy and Specialist Outpatients. Improved Ambulance Turnaround Times Kingston Hospital is now one of the best performing hospitals in London for ambulance turnaround times. An area has been designated for handovers which has improved privacy for patients and has ensured that patients are received promptly by a clinical team who can then commence early diagnostics and treatment. The Trust was also recently visited by colleagues at NHS England to look at our Ambulance Rapid Assessment and Planning processes. They were impressed with the changes that the department has made and asked the Trust to present at an NHS England/LAS forum and to provide guidance for Trusts who are currently failing this target. Improved emergency standard Improvements have been seen in the management of the emergency standard which requires patients to be admitted/discharged within 4 hours of attendance in the emergency department. Work has included the recruitment of additional consultants, the development of clinical pathways for medical and surgical patients, the investment in nursing manpower and the strengthening of links with the community and primary care. Whilst there is still further work to be done, the impact of the above changes has been evident to patients and staff. Joint Advisory Group on Endoscopy (JAG) The Trust was successful in receiving JAG accreditation for its endoscopy service. This requires compliance with a range of challenging standards which include clinical outcomes, audit, staffing profiles and access targets. Achievement of this was against a back drop of increased activity and demand for the service. This now provides the Trust with an opportunity to participate in the bowel screening programme in collaboration with St. George’s University Hospitals NHS Foundation Trust. Community Falls and Fracture Services In collaboration with our community colleagues, Kingston Hospital has set up a community falls and fracture service. All patients referred to the falls and bone health service will have a multi-factorial risk assessment with a physiotherapist, where any modifiable risk factors will be addressed. For those who have physical risk measures or fear of falling they will then start evidence based tailored exercise intervention. All exercise interventions can be carried out in patients homes or within exercise classes in their local community. Heart failure service We have two new full-time Heart Failure Nurses who joined the Trust in September 2015. They are running heart failure clinics as well as reviewing patients admitted to the Trust with heart failure. This will enable the Trust to ensure that our patients with heart failure are seen by one of the specialist team during their admission. We have a dedicated rapid access Heart Failure clinic at Surbiton Health Centre, led by Dr Pakrashi, Consultant Cardiologist.. The aim of the service is to provide evidence based care to those patients admitted to hospital with heart failure and to support community teams in managing this long term condition outside of hospital Kingston Hospital’s Stroke Services Kingston Hospital’s Stroke Unit has been awarded A and B grades for the stroke care it provides for its patients in the latest report from the Sentinel Stroke National Audit Programme (SSNAP). This is a fantastic achievement for the Trust as only 11 teams out of 202 in the UK have scored an A and the stroke service has steadily improved from C, to A and B in the last few years.

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SSNAP is the first national stroke register in the world to collect information across the entire stroke pathway, from admittance to hospital through to discharge, and aims to improve stroke care by measuring the quality of services against evidence-based standards. The results are updated every three months and cover all hospitals treating stroke patients in England and Wales, together with three hospitals in Northern Ireland. It is the most comprehensive and reliable source of information about the performance of stroke services. Single point of access geriatrician of the day (G.O.D) service Kingston has introduced a single point of access Consultant service to provide five day a week rapid access to telephone consultation and support for primary and community care clinicians. The 118 calls so far have been varied and have resulted in advice and the formulation of a joint management plans (2/3rds of cases), organising rapid outpatient COE reviews (22% of cases) and expediting inpatient investigations. This service has been well received by the primary and community care clinicians. Specialist Services Division Maternity, Paediatrics, Oral & Ear, Nose and Throat, Ophthalmology, Gynaecology & Breast, Sexual Health General Surgery &Urology ,Trauma & Orthopaedics and Dermatology & Plastic Surgery New Bereavement Suite at Kingston Hospital The Daisy Room, a new bereavement suite in Kingston Hospital’s Maternity Unit, was officially opened in 2015. The room is named after Daisy, a little girl who sadly died and whose parents helped raise money for the room. The new facility offers a private and comfortable space to give birth and provides a dedicated environment for bereaved parents to spend valuable time with their baby and family and create precious memories. The new suite was made possible by money raised by Daisy’s parents, donations from the Hospital’s Charity Born Too Soon and from Sands, the stillbirth and neonatal death charity, as well as Department of Health funding. Kingston Hospital Maternity Services committed to Baby Friendly Initiative Kingston Hospital’s Maternity Services have been awarded a Certificate of Commitment from the UNICEF Baby Friendly Initiative (BFI). This is the first award given by UNICEF UK in recognition that a provider has an infant feeding policy, an action plan to achieve Baby Friendly accreditation and the commitment to implement the plan. The Baby Friendly Initiative awards are designed to provide parents with the best possible care to build close and loving relationships with their baby and to feed their baby in ways which will support optimum health and development. At each stage the Services are externally assessed by UNICEF UK. When all the stages are passed they will be accredited as Baby Friendly. Award tables are maintained to let the public know how facilities are progressing. Newly Decorated Oncology Room Thanks to the charity Momentum, the Trust now has a Superhero-themed isolation room in the Paediatric Unit created by film set artist Amanda Dazely. The room was inspired by a young girl who was being treated for cancer and spent many months in the Sunshine Ward at Kingston Hospital. The funds for the makeover of the room were raised by the family and over £2,000 was raised for the installation of wall art.

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Oncology children often spend days or weeks at a time in isolation and the Superhero Room has been designed specifically with this in mind. It features a comic book style story in which the child in hospital can place themselves directly into the plot as the new superhero who needs to help the real superheroes find the magical crystal that will save the world from Bug Man’s evil plan. The newly decorated room provides distraction from the treatment being provided and makes the hospital environment fun. 3D Sensory Pain Distraction Unit in Paediatrics Momentum children’s charity has purchased a brand new 3D Sensory Pain Distraction Unit to be used in Kingston Hospital’s Paediatric Unit thanks to a £5,000 donation made by Kingston’s Hippodrome nightclub. The portable unit, which can be used during complex treatment and also more routine procedures that children have to go through such as blood tests or lumbar punctures, displays moving images on a screen to distract children in pain during treatment and procedures. The Pain Distraction Unit has proven results where it is being used in other hospitals across the UK, helping children to become distracted during stressful or painful procedures. New Paediatric Assessment Unit The Hospital now has a new Paediatric Assessment Unit (PAU) to provide ease of access to senior paediatrician review for acute paediatric referrals from primary care. This means Acute GP referrals are seen by a senior paediatrician (consultant/registrar) on the same day in a dedicated clinic and avoids the need to come via A&E. The PAU provides enhanced consultant delivered service, open 7 days a week, enhanced patient flow avoiding waiting times in A&E, patient observations avoiding the need to be admitted to the children’s ward, patient care and triage provided by paediatric nurses. New Macmillan Skin Cancer Clinical Nurse Specialist in Plastic Surgery & Dermatology Kingston was awarded a grant of just over £115,000 to fund the establishment of a Macmillan Skin Cancer Clinical Nurse Specialist to provide a continuous supportive service in the hospital and community, as well as information and education to those affected by skin cancer and their family and friends. The post will help meet increased referral demand due to increased incidence of skin cancer and will support delivery of Skin Cancer Pathways. The nurse will also be available to discuss any problems patients may be experiencing relating to their diagnosis, help with any anxieties or fears regarding skin cancer and offer practical support and advice with issues such as sun protection and checking their body or skin. Specialist Primary Care Orthodontist Service The Hospital has introduced a new Specialist Primary Care Orthodontic Service providing treatment to patients with complex orthodontic needs in a primary care setting. The service is available to patients living in Kingston and reduces the time that patients wait for treatment. The service links primary and secondary care to ensure patients receive care at the right place and can move seamlessly between providers without delay. Audiology Service Maintains IQIPS Accreditation The Audiology Service has demonstrated commitment to driving the quality of service provision and has maintained its IQIPS accreditation. Audiologists working for Kingston Hospital and Queen Mary’s Hospital were among the first in the country to receive a prestigious accreditation from the United Kingdom Accreditation Service (UKAS) in 2014. The service, which is run by Kingston Hospital NHS Foundation Trust, has received a ‘satisfactory’ rating under the Royal College of Physicians' IQIPS (Improving Quality in Physiological Services) programme.

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The IQIPS programme is sponsored by Professor Sue Hill, Chief Scientific Officer at the Department of Health. It has been developed to improve, promote and recognise good quality practice across the nine physiological disciplines. New Kingston Community Ophthalmology Service Kingston NHS Clinical Commissioning Group (CCG) has awarded the contract for Kingston’s Community Ophthalmology Service to a local consortium for 3 years. The local consortium - named Kingston Eye Network Community Ophthalmology Service (KENCOS) - is made up of Chambers (the local GP federation), Kingston Hospital and New Medica. The new service went live from 1 April 2016 and all patients seen by one of the current suppliers will be transferred to the new service. The new service brings together glaucoma diagnosis, monitoring of glaucoma and post cataracts as well as minor eye conditions, which were previously delivered by two separate community providers. Additional ophthalmology services will also be transferred from the Kingston Hospital site to a local community facility, in line with Kingston CCG’s wider strategy to bring care closer to home for local people, with shorter waits and delivering better care. New Data Management System Improves Patent Care in Ophthalmology Kingston Hospital’s Royal Eye Unit has implemented Topcon’s Synergy Ophthalmic Data Management System at the Trust which allows clinical staff to access easily and compare a multitude of different investigations - including OCT, angiograms and visual field tests - in one system and has resulted in improved patient care. The system allows staff to access and compare patient data from any networked database operated by a hospital, offering patients a more streamlined and efficient service. Direct Access to Ophthalmology Minor Ops Patients that have minor eyelid lumps and bumps can now be booked into dedicated, one-stop minor ops clinics, rather than oculoplastic clinics. This will allow patients to have their procedure on the same day as their consultation without an unnecessary additional appointment. This will also have the added benefit of creating greater capacity within oculoplastic clinics so more serious and major cases will not have to wait as long for an appointment. Expanding Assisted Conception Services The Trust has expanded its Assisted Conception Service into the community to ensure that patients are provided with a seamless pathway and care closer to home. We have started a fertility clinic at Raynes Park Health Centre that accepts referrals for any couple or single women who wish to conceive and where the GP and patient feel it is appropriate. Couples will usually have been trying to conceive for at least twelve months or have a known pathology that could affect their ability to conceive, including female age greater than 35 years. The assisted conception unit also successfully passed a service inspection carried out by the Human Fertilisation Embryology Authority this year. The service has been awarded a licence to continue to practice for a further three years. New staff appointments in Breast Service

Two Advanced Nurse Practitioners joined the Service in January 2016 as part of a service redesign to

drive quality and improve patient flow. The new structural alignment will enable the service to

commence an open access follow up programme (OAFU) for post treatment cancer patients later in

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the year. The OAFU programme will improve quality of service for our patients and is in line with

commissioning intentions for 2016-17.

Consolidation of Outpatient Breast clinics

The Breast service consolidated two one stop clinics from Queen Mary’s Hospital to Kingston in

January 2016. The move has increased outpatient capacity in the breast clinics and improved waiting

times for patients accessing the service. Consolidating the service has supported the maintenance of

the cancer waiting time standards.

Colposcopy Services Accredited The Colposcopy Service at the Trust continues to deliver high standards of quality and an effective and efficient service to their patients. Following a visit from Quality Assurance Assessors (QA) in January 2016, the service was awarded accreditation of a further three years. The draft report from the visit said the service demonstrated a dedicated team within colposcopy which communicates well through the colposcopy management meetings and with the HBPC and Trust management. There were no recommendations that required immediate action and overall, the teams interviewed demonstrated a strong commitment to the cervical screening programme and a keenness to improve it further. The Team also identified the importance of good communications and staff with dedicated time to run an efficient service. The model that was observed at Kingston was seen as a good example and be used for shared learning. New Urology 2-Week Wait Clinic The Trust has introduced a new dedicated Urology Two-Week-Wait clinic running weekly in the purpose-built Albany Unit at the Hospital, providing local care to local patients. The clinic sees all new two-week-wait patients with suspected urological malignancy (except bladder-see below) as referred in from primary care and via other specialities within the Trust to streamline patient pathways. Clinical Support Services Anaesthetics and Theatres, Intensive Care, Cancer and Palliative Care Services, Radiology, Pathology, Pharmacy and Therapies. Anaesthetics Accreditation Kingston Hospital’s anaesthetic department has received the Anaesthesia Clinical Services Accreditation (ACSA) in recognition of the excellent service it provides. A unique peer-review scheme developed by the Royal College of Anaesthetists (RCoA), ACSA enables departments to demonstrate quality in key areas, including patient experience and safe care. It has received acclaim from national regulators including the Care Quality Commission. The accreditation process gives the Trust the opportunity to review its risks and practices in line with college benchmarking for quality through ACSA recommendation. Obtaining this prestigious award is recognition that we are delivering a high quality service and are very pleased to know we are leading in patient care and safety standards. Cellular Pathology Accreditation The Cellular Pathology department has achieved the United Kingdom Accreditation Service (UKAS) accreditation for Medical Laboratories. UKAS is the sole national accreditation body for the United Kingdom and is recognised by government, to assess against internationally agreed standards. Accreditation by UKAS demonstrates the competence, impartiality and performance capability of the laboratory.

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The mortuary has retained its the Human Tissue Authority (HTA) licence, this now involves inspection of other areas of the Trust i.e. Maternity, A&E and Obstetrics and Gynaecology. The HTA regulates organisations that remove, store and use human tissue for medical treatment, post-mortem examination and research. The HTA regulations ensure that human tissue and organs are used safely and ethically, and with proper consent. Intensive Care Unit Innovation With the support of consultants and nursing staff a new Motomed Letto 2 machine has been purchased to facilitate the rehabilitation of very dependent critically ill patients by allowing passive and active assisted cycling in bed. This innovative approach allows patients who previously would have been too weak to engage in rehabilitation and physiotherapy to start engaging their muscles to passively cycle and facilitates circulation, the cardiovascular and respiratory systems. Following a presentation at a Patient First exhibition at London’s Excel Centre, a further Motomed cycling machine and an additional Caremed chair were donated to the intensive care unit at the Hospital allowing more patients to benefit from this new approach. E- Prescribing for patients The Trust is now using e-prescribing on all adult wards using the Care Record Summary (CRS) system and also has the iQemo system in operation for the prescribing of cancer chemotherapy prescribing. In addition to this, the Hospital’s Pharmacy has introduced the use of the Summary Care Record and Kingston Health Passport systems. These allow, with permission from the patient, access to GP prescribing details to enable more accurate medication histories to be known to the hospital staff.

Listening to patients The Trust is committed to involving patients and the public in the development and improvement of its services. Patient and public feedback is essential in ensuring that the services meet the needs and expectations of its patients and there are a number of mechanisms in place for obtaining patient feedback. Public and Patient Involvement in Service Improvement The Trust’s Patient and Public Involvement (PPI) Strategy was refreshed this year, having been developed in partnership with patients, Healthwatch, staff, governors, local stakeholders and the Patient Assembly and approved at the Trust Board in July 2013. The Trust’s vision for PPI is that Kingston Hospital will be an organisation that delivers care with people rather than to them. Friends and Family Test The Friends and Family Test (FFT) is used in all adult and children inpatient areas, A&E in Outpatient areas and in the Maternity Unit across the Hospital to get feedback on the care patients have received following their treatment or stay in hospital. The FFT asks them whether they would recommend Kingston Hospital to their friends and family based on their experience. Patients can rate their recommendation on a scale of six options, ranging from 'extremely likely' to 'extremely unlikely' and there is also an opportunity to give their main reasons for their answer and some feedback. Kingston was selected as a finalist in a national awards scheme for the Friends and Family Test. The awards were set up to recognise NHS providers who are going the extra mile in their work to listen to patients and staff. There were five categories and Kingston Hospital was shortlisted in two categories, FFT Champion(s) of the Year and Best FFT initiative in any other NHS-funded service. This year the Trust has introduced FFT in a number of new areas across the Trust including some Outpatient clinics, areas of the hospital that see and treat Paediatric patients and cancer services. In addition to this, the Trust has increased its FFT responses and scores. During April 2015 to March

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2016, over 25,511 responses have been received with more than 95% of respondents indicating a positive experience. The FFT results and scores are reported and monitored by the Trust’s Patient Experience Committee on a regular basis. Healthwatch Forum and Healthwatch Visits Local Healthwatch has a key role in gathering people’s views and experiences to the benefit of improving services at Kingston Hospital NHS Foundation Trust and across the local health economy. The Trust hosts a quarterly forum for all of the local Healthwatch groups that work with the Trust where senior representatives, including the Director of Nursing & Patient Experience and Trust Chairman, share details of how the Trust is performing and receive feedback regarding the local community’s opinions of how the Trust is viewed. This year, the local Healthwatch groups have been involved in developing the Trust’s Public and Patient Involvement Strategy and have engaged their membership in the Trust’s Quality Priorities for 2016-17. They have also carried out Enter and View visits in the Paediatric Department, Royal Eye Unit, Accident and Emergency and some of the medical wards at the Hospital as well as looking at the Trust’s discharge process to help identify areas of improvements for patients. Health Event Meetings The Trust has continued to hold health events during 2015-16, which have proved to be very popular. There were four in the last year, covering Cardiology, Chronic Obstructive Pulmonary Disease (COPD), Smokefree and Stroke. There are more events planned for the coming year. They are an excellent opportunity for the community to find out about services provided by the Hospital and to meet and question governors, directors and managers. Events included a presentation from a consultant or other healthcare professional and some practical demonstrations. Patient-Led Assessments of the Care Environment (PLACE) 2015-16 The Trust’s PLACE Assessment was carried out in May 2015 and the results were published nationally in August. The Hospital maintained a healthy involvement from Patient Representatives from Healthwatch and other patient groups. The Patient Reps thought the assessment was fair and commented that, whilst they found some of the questions difficult to answer, they were pleased with the way the assessment was carried out at Kingston Hospital. Their comments have been communicated back to the Health & Social Care Information Centre who administrate for PLACE. The good scores for Cleanliness and Condition and Appearance achieved in 2014 were maintained. Privacy, Dignity and Wellbeing showed an improvement on last year, the second year this has been the case, and now exceed the national average. Scores for Patient Catering vastly improved compared with last year and exceeds the national average. This reflects the hard work of the Trust, ISS and volunteers over the last year to raise the standard and suitability of the meals offered to our patients. This was the first time PLACE has been scored for Dementia for all Trusts. The Trust scored poorly compared with the national average. The Trust is working towards providing a better environment to meet the needs of patients with Dementia. The Trust will complete the next annual PLACE Assessment in April 2016. This year, the wording of some questions has been clarified and a selection of items previously scored as Condition and Appearance will be scored separately as ‘Disability Access’. New Patient Menus Following patient feedback, the Trust has made improvements to the Children’s Inpatient menu which now includes a variety of products that appeal to children and young people, such as toasted

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sandwiches, fish fingers and ice cream. The Trust has received positive feedback from patients of all ages and parents regarding the new menus. The Maternity Unit menu now has the capacity to provide meals outside of core catering hours. These are prepared and delivered by the nursing staff, which allows new mothers and other patients who may have missed a meal to receive a hot meal at any time of the day or night. Director of Nursing and Patient Experience Award The Trust has continued with the successful ‘Director of Nursing and Patient Experience Award’ which was introduced at the Trust last year. The award is to give recognition for a nursing professional who has really demonstrated all the four core values of the Hospital. The winner receives a bouquet of flowers donated from a local florist and is chosen from letters, emails and compliments received from patients and their relatives. This year, four awards have been made. CQC Inpatient Survey 2015 The tenth national survey of adult inpatient took place in July 2015 and was conducted by Picker on the Hospital’s behalf. The official results of the survey are expected in June 2016 and will be available on the CQC website. Maternity Survey 2015 The Picker Institute was commissioned by 64 Trusts to undertake the Maternity Survey 2015. A total of 397 women from Kingston Hospital were sent a questionnaire, of which 225 returned and completed it. The Hospital’s response rate was 57% compared to a national average of 41%. The results indicate that overall the Trust is performing on par nationally and as one of the best in London. It is rated as ‘better’ than others when women were questioned about partner involvement during the labour and birth. The responses nationally from women indicate they have had positive experiences as a result of being first seen by a midwife and always being spoken to in a way that is understood. Being treated with dignity and respect, having clean wards, toilets and bathrooms and more support for feeding also featured favourably in the survey responses. The Trust has significantly improved on three of the questions since the last survey was carried out in 2013. These included:

Infant feeding not fully discussed during pregnancy.

Postnatal Care at Home: Not offered visit by a midwife.

Postnatal Care at Home: Midwives were not aware of medical history.

Since the survey was carried out the Maternity Department have introduced a number of improvements:

Introducing the Baby Friendly Initiative including teaching of all staff in Breastfeeding support.

Appointing a second consultant midwife to enhance midwifery led care.

Introducing a harmony blood test to detect fetal abnormality such as Down's syndrome. This means that more women can avoid invasive testing which potentially put the foetus at risk.

Updating our maternity website proving extensive information for women and direct self-referral.

Neonatal Survey 2015 Kingston Hospital was one of 87 hospitals who participated in the National Neonatal Picker Survey which was conducted from October 2013 to September 2014 and was a sample of 200 parents of discharged infants.

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The Trust had a 45% respondent rate, which is higher compared to the national average. The results demonstrated that Kingston was rated in the top 20% for:

Staff being polite and introducing themselves

Information about the unit being explained

Parents feeling prepared for discharge.

Having enough information about Bliss and local support groups.

Most of the responses put the Hospital in the middle performing 60% of Trusts nationally and for a number of areas, including: A member of staff spoke to them about the Neonatal Unit before their infant was born, a photo was taken and given to parents, parents had confidence and trust in staff caring for their infant. Other areas where the Trust scored in the middle were: parents being able to talk about worries and concerns, nurses being sensitive to their feelings and consistent information was given by different staff, as well as emotional support, information about financial support, breastfeeding and formula feeding advice and staff including parents in discussion about care and treatments. Following the results, an action plan was put in place to improve the areas where the Trust was in the bottom 20%. Improvements included:

Major refurbishment of breast feeding room to improve facilities.

Screens for privacy to breast feed on the unit.

Baby Friendly Initiative introduced to achieve BFI level 1, including teaching of all staff in Breastfeeding support.

Three staff given supernumerary time specifically to help support breastfeeding.

New policies to support skin to skin, expressing and breastfeeding on the neonatal unit.

Refurbishment of the intensive care room including space gained from removal of central station.

Headphones were purchased to enable parents to stay in the room on ward rounds without risking breach in confidentiality.

Matrons office was redesigned to enable discussion room for parents, consultant and a nurse.

Rooming in rooms was negotiated on postnatal ward for infants and their parents to stay before discharge.

The ‘Whose Shoes’ tool was utilised to improve empathetic discussion between consultants and parents.

Improved discharge planning reduced the length of stay.

A new post created as a discharge planning coordinator to improve the process and promote early discharge.

All actions are completed and a repeat survey is planned for April 2015 onwards to monitor the improvements from a parents. Patient Advice and Liaison Service (PALS) The PALS service continues to offer frontline support and advice to those needing to raise a concern. It is accessibly located near the main entrance on the corridor leading to outpatients, and is well used by patients and visitors. 1574 cases were logged on the PALS database in 2015/2016. It is difficult to compare total figures of cases year on year as data entry parameters necessarily change according to the demands on the service, and the staffing levels. The data is, however, useful to identify themes and the most prominent three themes for 2015/16 were appointment administration concerns (accounting for

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46% of the concerns received), communication concerns (25%) and care and treatment concerns (10%). The PALS team works closely with patients and their relatives to ensure that their concerns are resolved at the earliest opportunity, and the team also provide information and signposting to enquirers. Complaints The Trust is committed to being patient focused, open and accountable, acting fairly and proportionately, putting things right and seeking continuous improvement. These principles guide the way all formal and informal complaints are managed. The Trust is committed to learning from any complaint received, and considerable focus is placed on this aspect of the complaints process. The Complaints team ensures that all complaints are robustly investigated and that, where action is needed to improve the care or service a patient received, this is reflected in the complaint response. Every reasonable effort is made to resolve complaints at a local level and this involves correspondence and meetings with complainants. In 2015/2016, the Trust received 465 formal complaints of which 19 related to car parking following the installation of the new system in October 2014. 446 represents an increase in complaints of less than 4% compared with the 430 received in 2014/2015. The Trust recognises that swift action in responding to complaints is key to resolving them. As such, we endeavour to respond within 25 working days to all complaints, or by the timeframe agreed with the complainant. During 2015/16 this deadline was met in 379 of complaints. Compliance with our response target is 82%, which is an improving trend compared to 75% in 2014/15, and work is ongoing to improve this response rate. Nationally, it is recognised that complaints have become more complex as services have expanded and there is more cross over with other local agencies and trusts. There is continued work with services lines to ensure complaints are responded to quickly and robustly. The Complaints Committee, chaired by a Non-Executive Director and attended by other Non-Executive and Executive Directors, met every quarter and received detailed information about current complaints and changes being made to improve services. Themes from complaints were identified and scrutinised, and service lines presented the changes they have implemented as a result of learning from complaints. In an effort to continually improve the complaints process for patients, each complainant is sent a questionnaire about their experience of the complaints process at the time the complaint response is sent to them. This feedback is then used to drive improvements. Complaints may highlight a need to change a practice or improve a service in an individual area. When identified, a change in practice will be implemented to avoid recurrence. Individual complaints (in an anonymised format) are used in training at all levels and for all staff. They are also shared at specialty level meetings and in other committees such as the Learning Disability Forum, Clinical Quality Review Group, and the Patient Experience Committee. Complainants’ stories are also shared with the Trust Board at their meetings.

Working with our partners At Kingston Hospital working with our partners is critical to patient care. Some of the key partnerships that help to make the Trust a success are:-

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South West London and Surrey Downs Healthcare Partnership (SHHP) The Trust is actively involved in the South West London and Surrey Downs Healthcare Partnership programme, which involves working in partnership with Clinical Commissioning Groups, other acute trusts, mental health providers, out of hospital providers, London Ambulance Services and Local Authorities. The objective of the partnership-working is to put South West London and Surrey Downs onto a clinically sustainable footing whilst maintaining and improving the quality of services provided to the local population. South West London Acute Provider Collaborative (SWLAPC) SWLAPC was set up last year to look at how Kingston Hospital, St George’s University Hospitals NHS Foundation Trust, Croydon Health Services NHS Trust and Epsom and St Helier University Hospitals NHS Trust could work together to increase the delivery of financially sustainable clinical services, focusing on collaborative opportunities to increase productivity, opportunities for increased clinical networking and supporting the Out of Hospital agenda. Kingston Co-ordinated Care Since August 2015 the Trust has been working with our partners Kingston Clinical Commissioning Group, Kingston Borough and YourHealthcare to develop a new model of health and care for adults with complex needs. The aim is to have a single pathway / one-stop-shop for the care they need, making it easier and simpler to access support. The model has been developed by a core design team of health and care frontline staff. The new model focuses on three steps:

Understand - Understanding the person

Plan - Planning their care with them

Do - Ensuring that the agreed care and support is provided

Richmond Outcome Based Commissioning (OBC) Richmond Clinical Commissioning Group is seeking to transform how they commission adult services with the focus on improved outcomes for patients. Kingston Hospital, Chelsea and Westminster NHS FT, Hounslow and Richmond Community Healthcare NHS Trust and the Richmond GP Alliance have been identified by Richmond CCG as the Most Capable Providers (MCPs) to develop the new model of care. The MCPs agreed a Memorandum of Understanding during 2015 and partners are working collaboratively across a number of clinical pathways in order to transition to an outcomes based commissioned service model. Accountable Clinical Network for Cancer Services in West London In July 2015 Kingston Hospital agreed to be a part of a Vanguard bid for an Accountable Clinical Network for Cancer Services in West London. The West London ACNC is led by the Royal Marsden and Kingston Hospital is working in partnership with the Royal Marsden and other partners to support integration across the entire cancer patient pathway to improve the delivery of patient centred cancer care. The Royal Marsden Hospital NHS Foundation Trust and Macmillan Cancer Support Our partnership with The Royal Marsden Hospital NHS Foundation Trust and Macmillan Cancer Support continues to deliver benefits to patients, both in terms of the delivery of treatment close to home and in the provision of high quality information and advice, all out of the dedicated Sir William Rous Unit on the Trust site. Within the unit, the Trust provides outpatient and diagnostic services with Macmillan Cancer Support providing information and support on the ground floor, whilst The Royal Marsden provides chemotherapy services on the first floor. St George’s University Hospitals Our working relationship with St George’s has continued, with a number of consultants with either joint appointments or clinical commitments at both hospitals, covering a range of specialties. These

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shared posts deliver excellent clinical links and improve partnership working across the specialties. They also help to make sure that patients are provided better care across the two hospitals and are ‘seen in the right place, at the right time, by the right person’. Queen Mary’s Hospital (QMH) For several years the Trust has provided a range of services at Queen Mary’s Hospital Roehampton on a recharge basis. A Memorandum of Understanding exists between the Trust and St George’s Hospital covering the provision of services provided at that site. The Memorandum of Understanding involves a subcontract for the provision of services across a range of specialties. BMI Healthcare Limited – Coombe Wing The Trust has worked in partnership with BMI Healthcare Limited over a number of years to provide private patient services on the hospital site. This includes the provision of private patient services, largely through the use of Coombe Wing and hospital facilities such as the operating theatres. South West London Elective Orthopaedic Centre (SWLEOC) The Centre is the UK’s largest dedicated hip and knee service providing world class orthopaedic care. The Centre is run by the four South West London acute trusts (Kingston Hospital NHS Foundation Trust, St George’s University Hospitals NHS Foundation Trust, Epsom & St Helier University Hospitals NHS Trust, and Croydon University Hospitals NHS Trust) to provide planned orthopaedic services to the patients of the four Trusts. Prime/ISS Prime Care Solutions (Kingston) Ltd is the company responsible for the funding and construction of the Kingston Surgical Centre, provision of soft services (cleaning, portering and catering) throughout the Hospital and hard services (building maintenance) in the Kingston Surgical Centre. The surgical centre opened in June 2007. Members of the consortium (and their responsibilities) are:

John Laing Investment Fund, 60% owners of the PFI project

Dolphin One, 40% owners of the PFI project

Prime Care Solutions (Kingston) Ltd manage the PFI project

Costain Ltd (construction of Kingston Surgical Centre)

ISS Facilities Services - Healthcare (soft facilities providers, such as cleaning, portering and catering, across the whole hospital site)

Cofely Gdf Suez (hard facilities provider such as building services operators and maintainers for the Kingston Surgical Centre).

Dalkia The Trust is aware of the need to take an environmentally sensitive approach to running the Hospital and is committed to reducing its carbon footprint. To achieve this, the Trust has entered into a partnership agreement with Dalkia, the leading European provider of energy services. Dalkia designed, built and financed a new energy centre on the Hospital site which went into service in November 2007. This modern, energy efficient engineering plant provides heating and cooling and generates electricity. The contract runs for 15 years (ending 2022) during which time Dalkia will provide energy and energy management services through the operation and maintenance of the systems on a mobile remote basis, supply all fuel and set up the electricity export agreement contract. Boots UK Kingston Hospital NHS Foundation Trust is working in partnership with Boots to provide a pharmacy service offering high quality, safe and person-centred care to outpatients and A&E patients. The service has demonstrated exceptional patient and customer care and has a team of health care professionals at the heart of delivering this. This is demonstrated in the Patient Satisfaction Survey

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results where 61% of patients were extremely likely and 39% of patients likely to recommend the pharmacy to friends and family if they needed care or treatment. A high % of ‘very good’ ratings were received for the following:

service received from the pharmacy

the time it took to provide the prescription

knowing about how to use the medication

knowing about how to obtain further supply of the medication Waiting times for patients are continuously measured and every month exceed the standard that 80% patients do not wait more than 15 minutes for their prescription. An average of 60 items/month are sent to local Boots stores for collection to prevent patients having to attend the Hospital. The pharmacy continues to provide extended hours of opening and the stocks a good range of pharmacy items for patients, visitors and staff to purchase. Local partnerships Volunteers 2015-16 has been a year of realising the true impact of volunteers across the Trust. This is the culmination of the Trust’s participation in the Centre for Social Action’s ‘Helping in Hospitals’ programme with Nesta and the Cabinet Office. In 2016 the Trust welcomed the 1,000th volunteer into the Volunteering Programme. This has enabled established programmes such as Dining Companions, Dementia Volunteering, Chaplaincy, Welcoming and Hospital 2 Home Volunteering to flourish with regular coverage across the wards and departments that need their support. As a result, the Trust and volunteers can be certain that their time is enhancing patient experience. This year, volunteers have helped to:

Improve patient satisfaction at mealtimes by 5%

Reduce anxiety amongst older patients at discharge by 48%

Improve the mood and wellbeing of patients with dementia by 42%

Connect more than 50% Hospital 2 Home patients to local charities and support groups We are very proud to report that our Friends & Family Test has demonstrated a clear overall relationship between the support that patients receive from volunteering and their overall satisfaction with their experience at Kingston Hospital. The Trust has established relationships with Kingston College Access to Midwifery programme, Richmond College’s Project Search, Esher College and sixth forms across local boroughs to create volunteering opportunities for young people and mature students aspiring towards careers in medicine, nursing, health care and health service administration. This has changed the way that we welcome younger volunteers aged 16 – 21 into the Trust who receive an unprecedented insight into hospital life through practical volunteering and intensive support from clinical and non-clinical staff. The newly approved Patient & Public Involvement Strategy has prioritised the way that the Hospital engages with the local community and voluntary sector. The refreshed strategy will focus on enabling people with protected characteristics and marginalised voices to volunteer, as well as accessing hospital services. Volunteers have influenced ongoing improvements and their unique perspectives are shaping the way the Hospital is run. The Quality Improvement Volunteers have supported a wide range of projects including the Pressure Ulcers Strategy, Sepsis Awareness Campaign, Dignity at Night and helped to shape the Trust’s Corporate Objectives. New forums such as ‘Come Dine With Me’ bring volunteers face-to-face with the staff and contractors who lead the Food & Nutrition Strategy to inform the ongoing improvement of menus and patient experience at mealtimes.

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We are exceptionally proud of new volunteering programmes in A&E and the Maternity Unit which see volunteers and staff working closely together to improve patient experience within a busy and often challenging clinical environment. Kingston Hospital NHS Foundation Trust is delighted to announce that the Trust’s Volunteering Service has this week been awarded the Kingston Quality Mark accreditation from Kingston Voluntary Action. This is a new quality assurance tool devised by Kingston First, Kingston Voluntary Action Group and advised by Stay Well, Help the Hospices and Kingston Hospital as a way to:

Reward and recognise good practice in volunteer management across the Borough Support small charities and organisations to follow best practice models with case studies

and practical guidance Enable the public to make informed decisions about where they invest their time as

volunteers Stand out as a Borough that celebrates volunteering as an asset of its community and way of

life

The Kingston Quality Mark accreditation sets out 10 key principles that guide best practice in volunteer management recognising the importance of respecting equality and diversity; reward and recognition; ensuring proper management of the volunteer journey through induction, personal development to providing a rewarding and safe working environment. Fundraising It has been a very busy year for the Kingston Hospital Charity as we have increased our presence within the hospital and local community to generate interest and funds in the work of the Charity. This was made possible by the employment of another part time member of staff to engage and develop relationships across the Hospital, aimed at generating income through events and community programmes with volunteers. However the main focus for the year has been on the Dementia Appeal and our relationship with The Mayor’s Charitable Trust. Dementia Appeal Over the last financial year the Appeal has developed organically within the community of Kingston Hospital and surrounding areas. This is mainly due to focusing on branding the Appeal apart from Kingston Hospital Charity and engaging with hospital staff and the local community. Coupled with the support of the Mayor of Kingston, Cllr Roya Arora, as the only nominated charity for 2015/16 we were able to make best use of the Mayor and nurture contacts to bring in an estimated £75,000 for the financial year. This was also made possible with the appointment of a Community Engagement Officer on a one year fixed term contract role. The Mayor’s term of office ended on 12 May 2016 but the relationship with him and his family has been instrumental in setting up the Appeal within the local community and we will continue to work with him to develop these relationships further moving forward. The Appeal itself is developing rapidly and we will be doing a summer mailing, based on previous success rates from Kingston CAN to be sent to various catchment areas within the borough of Kingston and surrounding areas to capture support from new and existing residents who may like to be a bit more involved. We have in the interim set up fundraising groups within the local community who help us generate income and educate people on the Hospital’s need for better environments of care in libraries, churches, social community groups, pubs, restaurants and hotels and this is only forecast to grow and develop over the next year.

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General Charitable Activities Over the course of the year Kingston Hospital Charity funded many projects and initiatives to support patients, carers, family members and staff which were constrained by budget restrictions of the NHS including:

£60,000 - Cardiology Holter System

£50,000 - End of Life Care Programme

£50,000 - Therapeutic Activities Programme

£30,000 – Specialist Orthopaedic Equipment

£20,000 – Staff Rooms & Patient Experience Improvements

£20,000 – Patient Wi-Fi access

£14,000 – Pharmacy Research & Development

£10,000 – Volunteering

£10,000 – Hospital to Home Programme

£10,000 – Urology Equipment

£10,000 – Balloon Sinoplasty

The Charity will be focusing on developing relationships across the hospital over the next year to manage and share the amazing work which is made possible by donors who have received treatments in different areas of the hospital. We will also be developing a more robust system for monitoring and evaluating how our donors’ funds are spent so we may be able to report back on these workings with a more holistic approach via social media and through our website. Born too Soon Born too Soon is a subsidiary Charity which fundraises specifically for the Neo-Natal Unit at Kingston Hospital. Born Too Soon celebrated its 30th Anniversary in 2015 which was a great achievement. We believe that the Neonatal Unit has cared for over 12,000 babies during that time. Many of the families still keep in touch and it is through these families that the majority of our fundraising takes place. In 2015-16 we had Rugby Matches, Golf Days, a run in St. James Park, and a Static Bike Ride on the Open Day. A parent led a Buggyfit Walk, which alone raised £8,500 with over 100 families taking part. We were the chosen charity of The Rotary Club of Kingston Upon at the Annual Dragonboat Challenge and they also donated over £3,000 for A Biliblanket. One of our Dads cycled from Lands End to John O’Groats - Darin Johnston, whose daughter was cared for on the unit 21 years ago. Mike Smith, a previous patient now an opera singer, also held several concerts to raise money. We were the chosen charity of Sainsburys Eden Street Kingston for two consecutive years. We were also chosen by Marks & Spencer, Kingston Branch as their community Charity for the year. To celebrate 30 years and give something back to our fund raisers, we held an Anniversary Ball at the Richmond Golf Club, attended by many families and staff from the hospital. Many improvements were made to the environment; refurbishment of our NICU and breast expressing room has made the parent experience much better. We have also purchased four vapotherms in order to give continuity to infants’ care returning from St Georges. These are a valuable addition to our respiratory care equipment. One of our achievements was our involvement with the design and helping fund the Daisy Room which is a dedicated bereavement room for families on Maternity, which was opened by Amanda Holden. The room is named after Daisy, a little girl who sadly died and whose parents helped raise money for the room. The new facility offers a private and comfortable space to give birth and provides a dedicated environment for bereaved parents to spend valuable time with their baby and family and create precious memories. Other key pieces of funding were spent on much needed specialist equipment for the unit and specialist nursing training.

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We held our Annual Graduates party which was attended by over 2000 neonatal graduates and is one of the openings for our fundraising with parents. We now have a DVD about the Neonatal Unit and also about the work of the Charity and a Website. Born Too Soon was a Finalist in the Kingston Business Awards and we are very proud to say that we were commended. Kingston CAN (Cancer Appeal) The Cancer Appeal continues to bring in funds to maintain and equip the Sir William Rous Unit at Kingston Hospital via a newsletter which is mailed to a database of just over 5,000 people twice a year. Since the Appeal started in 2000, the first piece of major equipment was purchased for the Unit at the end of 2015. The state of the art vacuum assisted breast biopsy equipment is now in use within the Breast Unit and has been instrumental in offering our patients a much improved and less painful and invasive breast biopsy. The Macmillan library and workshops continue to be very popular amongst the patients in our care and we will continue to support these financially for the foreseeable future. The fundraising team within Kingston Hospital Charity now have full responsibility for donor management and engagement moving forward. During the last newsletter, which went out in November 2015, we introduced the Kingston Hospital Dementia Appeal to engage with these existing donors on future mailings about the Hospital Charity and the work it does across Kingston Hospital. Over the next 12 months we will continue to develop the Dementia Appeal and work closely with other departments to underpin all the work which the Hospital Charity does across the hospital in a more meaningful and donor engaging way. This will ensure maximum donor retention for the Hospital Charity and we will also be able to follow our donors and supporters throughout their entire journey at Kingston Hospital in a more holistic way. This is part of our commitment to build on the goodwill and sense of community and family which is Kingston Hospital Charity. The Charity serves the community of Kingston and more importantly the bigger family of Kingston Hospital in its entirety. Momentum Momentum is a registered independent charity, established in 2004, that aims to help children (up to the age of 17) and the families of children, undergoing treatment for cancer and life-limiting conditions in Surrey and South West London. The charity is a long-term supporter of Kingston Hospital, initially providing a fridge for Sunshine and Dolphin Wards to stock ice creams for children with cancer, and has since transformed numerous treatment rooms and areas within the Paediatric Department. In this last year, Momentum has completed several new projects at Kingston Hospital. In June, superpowers came to one of the isolation rooms in the Paediatric Department, with a striking new Superhero-themed design. In December, the Teen Room got a fantastic face-lift, with beautiful Bohemian wall-art and a groovy new jukebox, transforming this room into the perfect chill-out zone for teenagers undergoing challenging cancer treatment. At the start of 2016, they unveiled a Moshi-Monster themed treatment room, using the popular Moshi characters to brighten up this well-used space within Dolphin ward. The Royal Eye Unit also saw their waiting room given a new lease of life, using Mo the Owl wall art. In addition, this year Momentum launched the first phase of a particularly exciting project – the refurbishment of Children’s A&E. The Charity has firstly redesigned the old waiting area, creating a sunny beach scene with robust new flooring, sturdy play tables, new toys and a drinks machine.

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The Charity also brightens up the days of children spending time within the hospital, through the arrangement of regular ‘character’ visits including Princesses, Hello Kitty and their popular Mo the Owl Mascot! They have provided new toys for many areas within the Hospital and are grateful to all those individuals and companies who have contributed. Momentum also extends support outside of hospital to children who have cancer or a life-limiting condition, and their families. Kingston Hospital refers families to the charity, who then offer individually-tailored support through their Family Support Programme, providing emotional and practical help as well as a range of therapy services including music, dance and drama. We are grateful for all the ongoing support from Momentum, and are looking forward to working with them over the coming year.

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Remuneration Report

The narrative elements of the Remuneration report are not subject to audit; the salary and pension information has been audited along with details on the median salary as a ratio of the highest paid director’s remuneration. The remuneration report includes details of the remuneration paid to the Chairman and directors of the Trust (the ‘senior managers’ who influence decisions of the Trust as a whole). Annual Statement on Remuneration Senior Managers who have served during 2015-16

Name Role Term of Office

Sian Bates Trust Board Chairman Appointed September 2013, reappointed with effect from September 2016 to 31 August 2019

Martin Grazier

Non-Executive Director Appointed February 2014, end of tenure February 2017

Sylvia Hamilton

Non-Executive Director Appointed January 2016 end of tenure January 2019

Michael Jennings

Non-Executive Director Appointed June 2010 left March 2016

Joan Mulcahy Non-Executive Director Appointed January 2011, end of tenure January 2018

Chris Streather

Non-Executive Director Appointed February 2014, end of tenure February 2017

Jacqueline Unsworth

Non-Executive Director Appointed March 2011, end of tenure March 2018

Ann Radmore Interim Chief Executive Interim from September 2015 and substantive from 1st May 2016

Rachel Benton

Director of Strategic Development and Acting Chief Executive from 16

July to 14 September 2016

Appointed March 2010

Duncan Burton

Director of Nursing & Patient Experience and Acting Chief Operating Officer from 16 July to 31 August 2016

Appointed February 2013

Eileen Doyle Interim Chief Operating Officer Appointed as an interim August 2015 to April 2016

Jo Farrar Director of Finance Appointed April 2015

Anne Robson Interim Director of Workforce Appointed as an interim March 2016

Jane Wilson Medical Director Appointed August 2009

Kate Grimes Chief Executive Appointed December 2008, retired March 2016

Terry Roberts Director of Workforce (non-voting) Appointed June 2014, left February 2016

Charles Bruce Deputy Chief Executive Appointed as an interim October 2014, appointed as substantive in February 2015 and left June 2015

Candace Imison

Non-Executive Director Appointed December 2009 left September 2015

Derek Macallan

Associate Non-Executive Director (Not remunerated)

Appointed for six months from January 2015

For Executive Directors in post during 2015-16 the notice period was three months.

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Payments for loss of office are made on the basis of contractual requirements under employment law. Remuneration Committee The Remuneration Committee of the Board sets the remuneration for the Chief Executive and Executive Directors. Membership The Committee is:

Chaired by the Chairman of the Board and attended by all Non-Executive Directors

The Chief Executive attends all meetings except those at which her salary and terms and conditions are being discussed

The Director of Workforce attends the committee in an advisory capacity

The Company Secretary attends the committee to take minutes The Committee’s role is to advise the Board about appropriate remuneration and terms of service for the Chief Executive and the other Executive Directors including:

All aspects of salary (including any performance related elements and/or bonuses)

Provision for other benefits including pensions

Arrangements for termination of employment and other contractual terms

The Committee also makes such recommendations to the Board on the remuneration and terms of service of Officer Members of the Board (and other senior employees) as are necessary to ensure they are fairly rewarded for their individual contribution to the Trust – having proper regard to the Trust’s circumstances and performance and to the provisions of any national arrangements for such members and staff where appropriate

Attendance at Remuneration Committee meetings During the course of the year the committee met five times.

Name Position Attendance

Sian Bates Chairman 4/5

Martin Grazier Non-Executive Director 3/5

Candace Imison Non-Executive Director until August 2015 1/2

Michael Jennings Non-Executive Director 4/5

Joan Mulcahy Non-Executive Director 3/5

Chris Streather Non-Executive Director 3/5

Jacqueline Unsworth Non-Executive Director 4/5

Sylvia Hamilton Non-Executive Director from January 2016 2/2

Nominations and Remuneration Committee The Committee considers the remuneration, allowances, appraisal process and other terms and conditions of office of the Chairman and the Non-Executive directors, taking into account benchmarking against other similar organisations including Foundation Trusts and taking specialist advice. The fees currently paid to the Chairman and the NEDs were agreed in May 2013 following recommendation from the Committee and have not been increased in the financial year. The Committee was established in May 2013. During the financial year 2015-16 it has met three times.

42

Agreed membership of the committee:

Chairman of the Foundation Trust who chairs the Committee

Lead Governor of the COG

One other elected governor

One appointed governor

Two other governors

The Senior Independent Director is in attendance and will chair the Committee when matters associated with the Chairman are considered

The Director of Workforce is in attendance in an advisory capacity

The Company Secretary is in attendance in an advisory capacity and to take minutes Attendance

Name Position Attendance

Sian Bates Chairman 3/3

Frances Kitson Lead Governor (elected public governor)

3/3

Marilyn Frampton Elected public governor 2/3

Professor Derek Renshaw until June 2015

Elected public governor 0/1

Professor Peter Tomkins Elected public governor 2/3

Dr Naz Jivani Appointed governor 2/3

Richard Allen from June 2015 Elected public Governor 2/2

The gross pay for Sian Bates as Chairman of the Trust for the period ending 31 March 2016 was £47,500. The gross pay for each of the non-executive directors was £13,500. Annual performance appraisals of the Non-Executive Directors are undertaken by the Chairman, with the Senior Independent Director doing so for the Chairman. The appraisals are based on their responsibilities and objectives agreed to support delivery of the strategic objectives of the Trust. The views of the governors are taken into consideration, with the Company Secretary liaising with the governors to provide feedback to the Chairman and the Senior Independent Director as appropriate. The Committee received confirmation from the Chairman and the Senior Independent Director that the appraisals had been completed, the outcome was given to the Committee and no performance issues were identified. The Committee considered the process for appointment of a Non-Executive Director. The Trust’s constitution states that the Council of Governors can remove the Chairman or a Non-Executive Director provided that the resolution to remove the individual has the approval of three-quarters of the members of the COG. The Council has not had to invoke this during the financial year. Senior Managers Remuneration Policy

Element Purpose and link to strategic objectives

Operation Maximum Opportunit

y

Performance Framework

Base Salary Provides fixed remuneration for the role, which reflects the size and scope of the Executive Director’s responsibilities.

Reviewed by the Remuneration Committee

Individual and business performance are considerations in setting base

43

– Attracts and retains the high-calibre talent necessary to deliver the business strategy.

salaries and in deciding on any increase in salary

Taxable Benefits

N/A N/A N/A N/A

Retirement benefits

To provide post-retirement benefits

Pensions are in compliance with the rules of the NHS Pension Scheme

Long-term incentives

N/A N/A N/A N/A

Chairman and Non-Executive Director Remuneration Policy

Elements of Pay Purpose and link to strategy Operation

Basic Remuneration

To attract and retain high performing Non-Executive Directors who can

provide the Board with a breadth of experience and knowledge.

Reviewed by the Nominations and Remuneration Committee who make recommendations to the

Council of Governors.

There are no provisions for the recovery of sums paid to directors or for withholding the payments of sums to senior managers. The Trust follows the National Agenda for Change for staff other than senior managers. Expenses Five senior managers claimed expenses during 2015-16 totalling £937.12. No expenses were claimed by Governors during 2015-16.

44

Annual Report on Remuneration a) Remuneration

There were no payments in the year in respect of "golden hellos", compensation for loss of office, or benefits in kind for any of the senior managers. As Non-Executive Directors do not receive pensionable remuneration, there are no entries in respect of pensions for Non-Executive Directors. b) Pension Benefits

c) Fair Pay Multiple 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 mid-point of the banded remuneration of the highest-paid director in Kingston Hospital NHS

Foundation Trust in financial year 2015-16 was £192,500 (2014-15 £192,500) excluding contractual

payments in lieu of notice. This was 5.5 times (5.4 times in 2014-15) the median remuneration of the

workforce, which was £35,000 (2014-15 median remuneration £35,900).

Salary paid

Taxable

Benefits

Annual

Performance

Related

Bonus

Payments

Long-term

Performance

Related

Bonus

Payments

Pension-

related

Benefits Total

(bands of

£5,000)

(rounded to

the nearest

£'000)

(bands of

£5,000)

(bands of

£5,000)

(bands of

£2,500)

(bands of

£5,000)

Ann Radmore, Interim Chief Executive from September 2015 55-60 - - - 7.5-10 65-70

Kate Grimes, Chief Executive until March 2016 220-225 - - - 165-167.5 385-390

Eileen Doyle, Interim Chief Operating Officer from August 2015 145-150 - - - - 145-150

Dr Charles Bruce, Deputy Chief Executive until June 2015 60-65 - - - (5)-(2.5) 60-65

Duncan Burton, Director of Nursing and Patient Experience 120-125 - - - 75-77.5 195-200

Jo Farrar, Director of Finance from April 2015 130-135 - - - 32.5-35 165-170

Jane Wilson, Medical Director 190-195 - - - 5-7.5 200-205

Rachel Benton, Director of Strategic Development 120-125 - - - 85-87.5 205-210

Terry Roberts, Director of Workforce until February 2016 95-100 - - - 55-57.5 155-160

Anne Robson, Interim Director of Workforce from March 2016 20-25 - - - - 20-25

Nicola Hunt, Director of Productivity, Innovation & Improvement until June 2015 20-25 - - - 0-2.5 20-25

Sylvia Hamilton, Non-Executive Director from January 2016 0-5 - - - - 0-5

Candace Imison, Non-Executive Director until August 2015 5-10 - - - - 5-10

Michael Jennings, Non-Executive Director until March 2016 10-15 - - - - 10-15

Joan Mulcahy, Non-Executive Director 10-15 - - - - 10-15

Jacqueline Unsworth, Non-Executive Director 10-15 - - - - 10-15

Sian Bates, Trust Board Chairman 45-50 - - - - 45-50

Chris Streather, Non-Executive Director 10-15 - - - - 10-15

Martin Grazier, Non-Executive Director 10-15 - - - - 10-15

Name and Title

Name and title

Real increase

in pension at

age 60

Real

increase in

pension

lump sum at

age 60

Total accrued

pension at

age 60 at 31

March 2016

Lump sum

at age 60

related to

accrued

pension at

31 March

2016

Cash

Equivalent

Transfer

Value at 1

April 2015

Real

Increase in

Cash

Equivalent

Transfer

Value

Cash

Equivalent

Transfer

Value at 31

March 2016

Employer's

contribution

to

stakeholder

pension

(bands of

£2500)

£000

(bands of

£2500)

£000

(bands of

£5000)

£000

(bands of

£5000)

£000

£000 £000 £000 £'000

Kate Grimes (Chief Executive until March 2016) 7.5-10 22.5-25 60-65 190-195 995 0 0 26

Ann Radmore, Interim Chief Executive from September 2015 0-2.5 2.5-5 65-70 205-210 1,383 44 1,443 22

Dr Charles Bruce (Deputy Chief Executive until June 2015) 0-2.5 0-2.5 35-40 105-110 687 6 701 3

Duncan Burton (Director of Nursing and Patient Experience) 2.5-5 5-7.5 25-30 70-75 294 44 341 17

Nicola Hunt (Director of Productivity, Innovation &

Improvement until June 2015) 0-2.5 -2.5-0 5-10 25-30 119 2 122 3

Jo Farrar (Director of Finance) 2.5-5 0-2.5 15-20 45-50 241 27 271 19

Jane Wilson (Medical Director) 0-2.5 5-7.5 70-75 220-225 1,501 57 1,576 24

Rachel Benton (Director of Strategic Development) 2.5-5 7.5-10 30-35 95-100 480 69 555 18

Terry Roberts (Director of Workforce until February 2016) 2.5-5 0-2.5 25-30 65-70 328 33 365 13

45

Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind as

well as severance payments. It does not include employer pension contributions and the Cash

Equivalent Transfer Value of pensions.



23rd May 2016 23rd May 2016

Kingston Hospital NHS Foundation Trust –Annual Report 2015-16

46

Staff Report

The average Whole Time Equivalent (wte) employed by the Trust this year is 2,503.95 wte in the following

staff groups:

The Trust continues to employ a predominately female workforce. Currently, 78% of our employees are female and trend data shows no significant change in the gender profile of our employees over the past five years. The table below breaks down the staff in post profile by pay band.

Payband Number of Female employees

% Female

Number of Male employees

% Male

Band 1 20 74% 7 26%

Band 2 407 77% 124 23%

Band 3 202 82% 45 18%

Band 4 152 86% 25 14%

Band 5 461 83% 97 17%

Band 6 394 85% 69 15%

Band 7 243 86% 40 14%

Band 8a 107 81% 25 19%

Band 8b 32 82% 7 18%

Band 8c 7 58% 5 42%

Band 8d 9 75% 3 25%

Band 9 2 67% 1 33%

VSM 2 40% 3 60%

Doctors 238 53% 209 47%

Total 2276 78% 660 22%

Board Members

Gender Head count %

Female 9 70%

Male 4 30%

Senior Leaders in the Trust

Gender Head count %

Female 157 80%

Male 40 20%

Staff Group Average WTE

Administration & Estates 551.51

Healthcare Assistants and Other Support 419.17

Medical & Dental 386.93

Nursing & Midwifery 829.14

Managers & Senior Managers 68.17

Allied Health Professions 114.82

Scientific, Theapeutic & Technical 120.54

Healthcare Scientists 13.67

Total 2503.95


47

All Trust Staff

Gender Head count %

Female 2,274 78%

Male 660 22%

Sickness

The average Sickness absence rate for 2015-16 is 2.97%. This is slightly above the Trust Target of 2.5%. The Trust has the second lowest sickness rate according to benchmarking against other Acute Small Hospitals nationally. Locally, in South London, the average sickness absence rate is 3.71%.

The pockets of high sickness in the Trust are within the Admin & Estates and Clinical Support staff groups.

Staff Group Average Sickness Absence Rate 2015-16

Clinical Support staff 4.66%

Admin & Estates 4.17%

Qualified Midwives 3.21%

Qualified Nursing 3.00%

Qualified Scientific & Technical 2.72%

Nursing Assistants 2.66%

Qualified Allied Health Professions 1.33%

Medical & Dental 0.84%

Total 2.97%

Average rate for Acute Small Hospitals 4.26%

Average rate for South London 3.71%

Equality and Diversity

The Equality & Diversity Committee oversees the Trust’s strategic agenda in terms of equality, diversity and human rights issues, taking account of changing legislation, best practice evidence, patients and staff feedback. In addition, the Committee agrees objectives and delivers an annual work schedule/plan. The Trust has also agreed for 2016 to – ‘Work to improve the experience of all staff members in the Trust and in particular Black, Asian and Minority Ethnic Groups (BAME)’ as a part of the Trust’s Strategic Objective 2.

The Trust publishes annual employment and service information, to demonstrate compliance with the Public Sector Equality Duty. Full reports regarding equality and diversity at the Trust can be found on the Equality and Diversity page on the Trust’s website.

The Trust continues to be compliant with its commitments as a Positive about Disabled People’s symbol user, which includes the following:

Interviewing disabled applicants who meet the minimum job criteria

Consulting annually with individual disabled staff through the appraisal cycle

Making every effort to redeploy staff who become disabled

Raising awareness of disability amongst staff

Monitoring and communicating annually progress and achievements in relation to the symbol requirements.


48

In 2015 the Trust provided 4 placements for students as part of its work with ‘Project Search’. Project Search is an employment-focused education programme, designed to give students with learning difficulties or an autistic spectrum disability the opportunity to learn more about the world of work, develop employability skills and to experience real life work placements.

Recruitment

During 2015-16 the Trust undertook a significant recruitment drive focusing on both qualified nurses and Healthcare Assistants. This involved holding a number of recruitment activities which included Overseas Recruitment and Cohort Recruitment Days.

The Trust also commissioned an external agency to assist with overseas recruitment and has been successful in recruiting 97 additional nurses from the Philippines, Italy, Spain and Portugal since March 2015. All our overseas nurses are provided with a structured induction programme, with further ward based support.

This surge of overseas recruitment has helped to fill our qualified nursing vacancies and contributes to our diverse workforce. Looking ahead, we have an additional 82 nurses in the recruitment pipeline which we aim to have in post by August 2016, further reducing our WTE deficit and bringing us closer to our aim of 95% fill rate for qualified nurses.

Occupational Health & Wellbeing Service

Our Occupational Health & Wellbeing Service promotes the physical and mental wellbeing of people at work, helping them to work safely and effectively to maximise the success of the organisation. In the past year the Occupational Health and Wellbeing service has been assessed by the Faculty of Occupational Health Medicine and maintained their “Safe, Effective Quality Occupational Health Services” (SEQOHS) accreditation, which endorses our service.

Income generation: Occupational Health (OH) is in a strong position to income generate and has small contracts which we have held for some years and we are actively looking to increase these. We have acquired South West London/St Georges Mental Health Trust as a client, with the remainder of the MHT moving to Kingston for their OH provision on 1 April 2016. Occupational Health has also made a successful bid in collaboration with the Health at Work Network to provide assessments for the Government’s ‘Fit to Work’ programme, which was due to commence in June 2015, however to date we do not have any referral for this.

In terms of Health & Wellbeing, Occupational Health has significantly increased the number of lifestyle events and therapies offered to staff at reduced rates; of particular note are the Yoga, Pilates, and Circuit training. A monthly health promotion event is being introduced from April 2016 and this will include: -

Vacancy Rates Budget

Wte

Actual

Wte

Vacant

Wte

Vacancy

Rate as at

Mar-16 (latest data)

Target

Wte (95% fill

rate)

WTE to fill

Qualified Nursing 779.04 692.09 86.95 11.16% 38.95 48.00

Admin & Estates 689.69 656.42 33.27 4.82% 34.48 -1.21

Medical & Dental 437.63 416.78 20.85 4.76% 21.88 -1.03

Nursing Assistants 278.39 271.39 7.00 2.51% 13.92 -6.92

Qualified Allied Health Professions 125.53 111.60 13.93 11.10% 6.28 7.65

Qualified Scientific & Technical 149.35 137.98 11.37 7.61% 7.47 3.90

Qualified Midwives 188.20 178.52 9.68 5.14% 9.41

Clinical Support staff 175.51 178.36 -2.85 -1.62% 8.78

Total 2823.34 2643.14 180.20 6.38%


49

Blood pressure and cholesterol checks, advice on healthy lifestyles, including smoking cessation, diet and fitness.

Valuing staff

The Trust aims to have a committed, skilled and highly engaged workforce who feel valued, supported and developed and who work together to care for our patients.

Staff Engagement

As part of the Board’s ongoing Engagement Plan to communicate with staff and to hear their views the following took place:

Communications in Monthly team brief, CEO weekly newsletter and (on screens around the Trust) details of programmes of work undertaken in response to patient feedback

Board and Governor walkabout programme

Safety walkabouts (Executive rounding) are to be developed as part of the Trusts participation in the Patient Safety Collaborative

Executive board members working alongside staff o As dining companions o Shadowing o Participating in induction and welcome events

Listening events

Board meetings at which a story from a patient, staff member or volunteer is given. This provides an opportunity for the Board to connect with patients, relatives, front line staff and volunteers on an emotional level; to understand the impact of the experience on the patient and their perspectives on a particular event or issue; to appreciate the human aspects of harm and errors and develop an open culture to learn from errors and to make the experience of the patient, staff member or volunteer personal to the Trust at all levels, recognising that ‘this experience happened here’.

Annual General Meeting/Annual Members Meeting (AGM/AMM)

Workshops and seminars

Quarterly conversations with the Board on particular themes with open access for all staff

Quarterly meetings are being established for Board members to meet with junior doctors

Facilitated training for sisters/charge nurses on how they can use experience information to drive improvement.

Improved induction of new nurses & nursing assistants to the organisation

Continued focus on reducing vacancies and keeping communications regarding the importance of this

Celebratory measures – the monthly flowers award for nurses & midwives, the

Nursing & midwifery celebratory conference

Increased practice development involvement at ward level

Other means of engaging included:

Commissioning a series of workshops on ‘Positive about Kingston Hospital’, which looked at how we can learn from our successes and keep improving by taking a positive approach

Implementing the Paired Learning Leadership Programme

Business planning with service lines which has included market place events to support service lines to communicate with each other and with corporate support areas in developing their planning

The clinical governance infrastructure enables multi-disciplinary discussions on clinical issues and service improvement


50

Clinical Quality Improvement programmes

Further improvements to the staff intranet which is being increasingly followed by staff and the public on the Trusts official Facebook page and Twitter sites – contributes to developing ‘conversations’

Annual NHS Staff survey and internal surveys and action planning

Annual appraisal process for staff

Range of interventions to improve the style and people management skills of Line Managers

A move to an inpatient experience plan encompassing the feedback from multiple sources, with focus on tackling the key themes

‘You said, we did’ campaigns outlining key changes made in response to feedback

such as the menu changes, ward sister uniforms, visitors

A greater visibility and analysis of qualitative information from the Friends & Family test at departmental level

The ‘Leading for Improvement’ team development sessions including focusing on what local areas can do to improve team working and patient experience

In 2015-16 the Trust continued to focus on improving how people are managed in the Trust so that we continue to have highly engaged staff, well managed by their line managers and to enable productive conversations across the Trust. The Trust did this by:

Implementation of the KHFT Coaching Strategy which embraced the vision of creating a coaching culture across the Trust. The Coaching Strategy sets out the rationale for developing a coaching culture across the Trust and links good people management practices to engaged staff delivering exceptional care to patients and their loved ones.

Development of a competency framework for Service Managers and designing a Development Centre to assess competencies. This was refined further to aid development of talent management and succession planning for Service Managers.

Enabling staff to provide feedback on their managers’ people management skills. A total of 965 staff members provided feedback to 232 managers on their people management skills through the Managers Staff Feedback process which formed part of their annual appraisal discussion. The questionnaire enables an appraiser to have a discussion about the feedback from the individual’s direct reports, where they are doing well and where they need to work on improving their skills. Actions to improve are then built into the objectives setting with clear support in the personal development plan as appropriate.

Launching a new appraisal process to ensure that personal development plans are not only completed, but also acted on and that training which is commissioned is developed from the learning needs analysis taken from the personal development plans of staff themselves.

Development programmes for band 6 nurses, theatre sisters, site practitioners and A&E sisters

Greater visibility of opportunities for nursing assistants to apply for sponsorship to nurse training

Team development days for ward based staff

Monthly Staff Awards

The Trust continues to perform well due to the tremendous commitment and contributions from staff. The

Trust’s Monthly Staff Excellence Award scheme has been successfully running for over three years which

gives recognition to staff who go above and beyond the call of duty and live the Trust’s values. Since April

2015 there have been 22 staff award winners.

Patients and staff members can nominate someone they feel deserves the award under the Trust’s four values which are Caring, Safe, Responsible and Value Each Other. Once all the nominations have been


51

received, they are viewed by the Directors and a winner is agreed. Each month the winners receive a £25 gift card, a certificate and a mug in recognition of their achievement.

Annual Staff Excellence Awards

This year, the Trust held their very first Annual Staff Awards evening, celebrating the hard work of its staff.

The evening was the opportunity to recognise the outstanding work and congratulate dedicated staff

across the Trust. Members of staff, patients, volunteers and carers were invited to nominate staff who had

shown commitment to the Trust’s core values of Caring, Safe, Responsible and Value Each Other.

There were 14 award categories incorporating the values with a total of 35 awards presented on the evening including ‘frontline and behind the scenes teams of the year, patient’s choice, positivity champion and unsung hero of the year’. The awards were hosted by TV presenter and local resident Angellica Bell and the evening was sponsored by Drake Medox, April Strategy, ISS Facility Services and Prime Care Solutions (Kingston).

Severance payments

Agreements number

Total Value of Agreements

£000

Voluntary redundancies including early retirement contractual costs

Mutually agreed resignations (MARS) contractual costs

Early retirements in the efficiency of the service contractual costs

Contractual payments in lieu of notice 6 87

Exit payments following Employment Tribunals or court orders

Non-contractual payments requiring HMT approval *

Total 6 87

Of which:

non-contractual payments requiring HMT approval made to individuals

where the payment value was more than 12 months of their annual

salary

0 0

Exit package cost band Number of compulsory

redundancies

Number of other departures

agreed

Total number of exit packages by cost band

<£10,000 4 4

£10,00 – £25,000

£25,001 – £50,000 2 2

£50,001 – £100,000

£100,000 – £150,000

£150,001 – £200,000

etc.

Total number of exit packages by type 0 6 6

Total resource cost 87 87


52

Staff Survey The National Staff Survey results in 2015 showed an improved picture for the Trust this year with 57% of the questions receiving an improved score since 2014.

Summary of performance – results from the NHS staff survey For the 2015 survey the Trust for the first time conducted a full survey of all substantive employees with 1,106 staff responding giving the Trust an overall response rate of 46% which was slightly above average compared to other acute trusts in England where the responses rate was 45%. Historical Staff Survey Results

2014-15 2015-16

Response rate Trust National Average

Trust National Average

45% 50% 46% 45%

Top 5 ranking scores

2014-15 2015-16

Trust National Average Trust National Average

% experiencing physical violence from patients, relatives or the public in last 12 months

10% 14% 11% 14%

% reporting good communication between senior management and staff

32% 30% 38% 32%

% appraised in last 12 months 95% 85% 91% 86%

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

29% 26% 54% 59%

agreeing that they receive support from their immediate Manager

3.63 3.65 3.78 3.69

Bottom 5 ranking Scores

2014-15 2015-16



% working extra hours 78% 71% 76% 72%

% reporting most recent experience of violence

- - 45% 53%

reporting satisfaction with resourcing and support

- - 3.21 3.30

% believing that the organisation provides equal opportunities for career progression or promotion

81% 87% 82% 87%

% experiencing harassment, bullying or abuse from staff in the last 12 months

31% 23% 29% 26%


53

Workforce Race Equality Standard (WRES)

In terms of 4 specific staff survey questions relating to the Workforce Race Equality Standard, the results detailed below showed an improved picture for the Trust this year with an improved score since 2014 from BAME respondents.

2014-15 2015-16

Trust

Average Acute Trusts

Trust Average

Acute Trusts

Trust Improvement/ Deterioration

% experiencing harassment, bullying or abuse from patients, relative or the public in the last 12 months

White 29% - 30% 28% 1%

deterioration

BAME 35% - 28% 28% 7%

improvement

% experiencing harassment, bullying or abuse from staff in the last 12 months

White 29% - 28% 25% 1%

deterioration

BAME 43% - 32% 28% 7%

improvement

% believing that the organisation provides equal opportunities for career progression or promotion

White 88% - 88% 89% -

BAME 66% - 69% 75% 3%

improvement

% in the last 12 months who have personally experienced discrimination at work from manager/team leader or other colleagues

White 8% - 6% 6% 2%

improvement

BAME 24% - 15% 13% 9%

improvement

Future priorities and targets

A number of key actions and improvements have been implemented over the course of 2015-16 and will continue to be implemented over the course of 2016-17 as follows:

To complete the recommendations identified in the Baseline Survey which include: o Regular reminders within CEO newsletters about how coaching becoming the predominant

style of managing and working together; o The Executive Management Committee (EMC) encouraging and ensuring that all our

managers have the opportunity to undertake the Coaching Approach for one to ones and appraisals;

o Senior leaders taking responsibility in speaking about coaching and the positive impact that coaching has.

o investing in some additional development activities to raise awareness of coach training to all staff

o Manager’s Coaching Award to be incorporated in our monthly Staff Awards Scheme and clear examples of how the Manager used a coaching approach to engage and empower team members;

o A corporate approach in communicating improvements across the Trust; o An Annual Staff Engagement Celebratory Lunch to recognising good management practices

across the Trust. o Undertake a further evaluation using the Megginson & Clutterbuck Coaching Culture Tool

in October 2016;


54

o Improving the experience of all staff members in the trust and enhancing the way we work together to improve services for patients

o Full launch of the ‘Speaking in Confidence’ system to enable anonymous feedback and will also provide a way of quantifying the experience so that the Board has visibility of this.

Detailed analysis of the issues identified by staff in the staff survey ensuring that this data is triangulated with data from the exit interviews, retention surveys and occupational health information. For the 2015 Staff Survey action plan the focus will be on looking at the bottom five ranking scores compared to other acute trusts, in particular a focus will be on staff working extra hours and staff experiencing harassment, bullying or abuse and formulating action plans to improve these areas for the employees.

2015/16

Number of

engagements

Number

No. of existing engagements as of 31 Mar 2016 6

Of which:

Number that have existed for less than one year at the time of reporting 0

Number that have existed for between one and two years at the time of reporting 4

Number that have existed for between two and three years at the time of reporting 1

Number that have existed for between three and four years at the time of reporting 1

Number that have existed for four or more years at the time of reporting 0

Confirmation:

Please confirm that all existing off-payroll engagements, outlined above, have at some

point been subject to a risk based assessment as to whether assurance is required that

the individual is paying the right amount of tax and, where necessary, that assurance

has been sought.

Yes

Table 4B: For all off-payroll engagements as of 31 Mar 2016, for more than £220

per day and that last for longer than six months

2015/16

Number of

engagements

Number

Number of new engagements, or those that reached six months in duration between 01

Apr 2015 and 31 Mar 20162

Number of the above which include contractual clauses giving the trust the right to

request assurance in relation to income tax and national insurance obligations2

Number for whom assurance has been requested 2

Of which:

Number for whom assurance has been received 0

Number for whom assurance has not been received * 2

Number that have been terminated as a result of assurance not being received 0

Table 4C: For all new off-payroll engagements, or those that reached six months

in duration, between 01 Apr 2015 and 31 Mar 2016, for more than £220 per day

and that last for longer than six months


55

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

2015/16

Number of engagements

Number

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

0

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

19

The Trust’s expenditure on consultancy during 2015-16 was £502,000.

In any cases where, exceptionally:

- the trust has engaged without including contractual clauses allowing the trust to seek

assurance as to their tax obligations; or

- where assurance has been requested and not received, without a contract

termination

please specify the reasons for this.

In both cases assurances have not been received in a timely manner, the Trust is

continuing to pursue responses from the individuals concerned. Both contracts had

been terminated for other reasons by 31 March 2016.


56

NHS Foundation Trust Code of Governance

Corporate Governance The Board is responsible for the management of the Trust and for ensuring proper standards of corporate governance are maintained. The Board accounts for the performance of the Trust and consults on its future strategy with its members through the Council of Governors (CoG). The Board also acts as the Corporate Trustee for the Kingston Hospital Charity. The CoG’s role is to influence the strategic direction of the Trust so that it takes account of the needs and views of the members, local community and key stakeholders, to hold the Board to account on the performance of the Trust, to help develop a representative, diverse and well-involved membership, and to help make a noticeable improvement to the patient experience. It also has to carry out other statutory and formal duties, including the appointment of the Chairman and non-executive directors of the Trust and the appointment of the external auditor. Governance structure The Trust’s constitution was ratified in May 2013 on Authorisation as a Foundation Trust. A small number of changes were made to the constitution in the year 2012-13 to incorporate statutory changes required under the Health and Social Care Act 2012, including the availability of documents for public inspection and the scrutiny of the CoG over activities generating non-NHS income. Further changes were agreed in subsequent years to reflect changes to the model election rules and changes in legislation. The Trust continues to be open and transparent with the community through the public CoG meetings, the various health events held during the year, the local interest groups and the large amount of information available on the Trust’s website. The Board of directors (the Board) of the Trust attaches great importance to ensuring that the Trust operates to high ethical and compliance standards. Kingston NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in 2012.


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Directors The biographies of the directors who held office during the year appear on in the Directors’ Report. Chairman The Chairman of the Trust is Sian Bates, a Non-Executive Director who chairs the Council of Governors and the Board. Deputy Chair Candace Imison was the Deputy Chair of the Board until 31 August 2015, since then Jacqueline Unsworth has taken on the role. Senior Independent Director During 2015-16 the Senior Independent Director was Michael Jennings, whose appointment to the position was ratified by the Council of Governors on authorisation in May 2013. Part of the role of the Senior Independent Director is to provide another route for communication with Governors if they feel unable to raise a particular concern through the Chairman. The Senior Independent Director also undertakes the Chairman’s appraisal, after seeking feedback from the rest of the Board, and from Governors and partners. In March 2016 the Board and Council of Governors agreed the appointment of Chris Streather as the Senior Independent Director with effect from 1 April 2016. The Board The Board meets regularly and has a formal schedule of matters specifically reserved for its decision. This includes high level matters relating to strategy, business plans and budgets, regulation and control, annual report and accounts, audit, and monitoring how the strategy is implemented at operational level. The Board delegates other matters to the Executive Directors and senior management. The Board met at six scheduled meetings during the year under review plus five development meetings. Regular contact, including with the Non-Executive Directors, is maintained between formal meetings. Board meetings follow a formal agenda, which includes a review of quality and patient care, strategy, clinical governance, operational performance and performance against quality indicators set by the Care Quality Commission (CQC), Monitor and by management, such as infection control targets, patient access to the Trust and Emergency Department waiting times. The Directors have timely access to all relevant quality management, financial and regulatory information. On being appointed to the Board, Directors are fully briefed on their responsibilities. Ongoing development and training requirements for individual Directors are assessed annually through the appraisal process, with the Chairman leading on collective Board development, which is addressed at Board workshops. Directors’ remuneration Details of the directors’ remuneration, fees and expenses for the year and their service contracts and Letters of Appointment are set out in the Remuneration Report. The accounting policies for pensions and other retirement benefits are set out in note 9 to the accounts. Appointment, re-election and the Nominations Committee The Directors are responsible for assessing the size, structure and skill requirements of the Board, and for considering any changes necessary or new appointments. If a need is identified, in the case of an Executive Appointment the Remuneration Committee, which comprises of the Chairman and the Non-Executive Directors assisted by the Director of Workforce, will produce a job description, decide if external recruitment consultants are required to assist in the process and if so instruct the selected agency, shortlist and interview candidates. If the vacancy is for a Non-Executive Director, the Nominations and Remuneration Committee comprising of 5 members of the Council of Governors (CoG), the Chairman, with the Senior Independent Director, the Director of Workforce and the Company Secretary in attendance, considers the matter.


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Non-Executive Directors are appointed for a three-year term in office. A Non-Executive Director can be re-appointed for a second three-year term in office on an uncontested basis, subject to the recommendation of the Nominations and Remuneration Committee and the approval of the CoG. A Non-Executive Director’s term in office may, in exceptional cases, be extended beyond a second term on an annual case-by-case basis by the CoG, subject to a formal recommendation from the Chairman, satisfactory performance, and the needs of the Board, without the Trust having to go through open process. Removal of the Chairman or another Non-Executive Director shall require the approval of three-quarters of the members of the CoG. The Chairman, other Non-Executive Directors, and the Chief Executive (except in the case of the appointment of a new chief executive) are responsible for deciding the appointment of Executive Directors. The Chairman and the other Non-Executive Directors are responsible for the appointment and removal of the Chief Executive, whose appointment requires the approval of the CoG. Directors and their independence At the end of the financial year, the Board comprised the Chairman, six executive directors and six non-executive directors. The Board has formally assessed the independence of the Non-Executive Directors and considers that there are no relationships or circumstances that are likely to affect their independent judgement. All Directors have made declarations in accordance with the Trust’s Register of Interests Policy. At each meeting Directors are reminded to declare interests in matters to be discussed and any declarations made are recorded in the minutes. Register of directors’ interests The register of directors’ interests is available for inspection during normal office hours at the Chief

Executive’s office and is published on the Trust’s website.

Trust auditors Grant Thornton are appointed as the Trust’s external auditor. KPMG are the Trust’s internal auditors.

Board Committees The Board has the following committees:

Strategy Committee (removed from the structure during 2015-16 as recommended in the Well Led review report)

Quality Assurance Committee

Finance and Investment Committee

Audit Committee

Workforce Committee (established March 2015)

Remuneration Committee

Trust and Charitable Funds Committee

Details of the roles of these committees are included in the Annual Governance Statements.

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


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Company Secretary

The Board has direct access to the advice and services of the Company Secretary (Secretary), who is responsible for ensuring that the Board and committee procedures are followed. The Secretary is also responsible for ensuring the timely delivery of information and reports. The Secretary is responsible for advising the Board, through the Chairman, on all corporate governance matters.

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Sian Bates 6/6 2/4 12/12 4/5 4/5 6/6 4/5

Martin Grazier 6/6 4/5 9/12 3/5 5/5 4/5

Candace Imison 2/2 0/2 1/2 3/3 0/1

Sylvia Hamilton 2/2 1/1 In attendance

as future member of

the Committee

2/2 2/2

Michael Jennings 5/6 5/5 4/4 10/12 4/5 5/6 4/5

Joan Mulcahy 6/6 5/5 8/12 In

attendance as Audit

Committee Chair

4/5 3/5 4/5

Chris Streather 4/6 3/5 1/5

Jacqueline Unsworth

4/6 3/5 4/5 2/5

Derek Macallan 1/1 1/1

Kate Grimes to July 2015

1/1 0 0/1 0/2 1/2 1/1

Ann Radmore from September

2015

4/4 0 5/8 0/2 3/3 1/2 4/4

Jo Farrar 6/6 3/4 11/12 5/5

Duncan Burton 6/6 4/12 4/5 6/6 4/5

Jane Wilson 6/6 5/5 1/6 3/5

Charles Bruce 2/2 2/3 2/2 0/1

Eileen Doyle 2/4 4/9 3/3 3/4

Rachel Benton 6/6 5/12 3/5

Nicola Hunt to June 2015

0/1

Terry Roberts to February 2016

4/5 6/6 0/4

Anne Robson From March 2016

1/1 N/A 0/1


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Statement of compliance with the NHS Foundation Trust Code of Governance

The Board of Directors considers that it was compliant with the provisions of the revised NHS Foundation Trust Code of Governance. The Council of Governors retains the power to hold the Board of Directors to account for its performance in achieving the Trust’s objectives.

Counter Fraud

The Trust is committed to providing and maintaining an absolute standard of honesty and integrity in dealing with the Hospital’s assets. The Board is committed to the elimination of fraud and illegal acts within the Trust, and to ensure rigorous investigation and disciplinary or other actions as appropriate. The Trust adopts best practice procedures to tackle fraud, as recommended by NHS Protect.

The Trust has an overarching Counter Fraud Policy and Guidance document and an active counter fraud team which supports the Trust in countering fraud and corruption and has developed protocols with the HR, Purchasing and Finance teams to ensure the counter fraud culture is embedded within the work of the Trust.

Over the year, the Hospital has widely published the Trust’s policies and procedures for staff to report any concern about potential fraud. This has been reinforced by awareness training. Any concerns are investigated by the local counter fraud specialist or NHS Protect as appropriate. All investigations are reported to the Audit Committee.

Managing Public Money

The Trust has complied with HM Treasury’s guidance ‘Managing Public Money’, which set out the steps public bodies should take where they have caused injustice or hardship by maladministration or service failure. This includes setting up systems for dealing with complaints promptly and consistently, setting out what remedial measures need to take place and reporting ex-gratia payments to those charged with governance.

Quality Governance

An overview of the arrangements in place to govern service quality is included in the Quality Report and Annual Governance Statement. The Trust is implementing service line management, this allows the Trust to embed this in the organisation led by the Head of Quality Governance, clinical leads, Quality Improvement Leads for Patient Safety and the Corporate Risk Manager overseen by the Quality Assurance Committee and sub-committees.

Council of Governors and Membership

Council of Governors

Role of the Governors The Council of Governor is responsible for the appointment of the Chairman and the Non-Executive Directors, and agreeing their terms and conditions, as well as the appointment of the external auditor. Each financial year, the Council of Governors is consulted by the Board on the Trust’s forward plans and receives the Annual Accounts, Auditors’ Report, Annual Report and Quality Report. Governors respond as appropriate when consulted by the directors on specific issues. Governors are unpaid. However they are entitled to receive reimbursement of expenses, which were not claimed in 2015-16. Lead Governor The Council of Governors select one of their elected members to be the Lead Governor of the Council of Governors. The Lead Governor co-ordinates any communication between Monitor and the other Governors and acts as a main point of contact for the Chairman and the Senior Independent Director. The Lead


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Governor at the date of this report is Frances Kitson, Elected Governor for Kingston. The Council of Governors has selected a Deputy Lead Governor to deputise for the Lead Governor as necessary. The Deputy Lead Governor at the date of this report is Richard Allen, Elected Governor for Kingston. The Council of Governors is chaired by the Trust’s Chairman and supported by the Company Secretary and the Assistant Company Secretary. The Council comprises of:

17 elected public Governors

4 elected staff Governors

12 Partner appointed Governors Membership and terms of office of the Council during 2015-16 are outlined below.

Name

Appointing Organisation/Constituency Term of office

Attendance at Council of Governors meetings during 2015-16

CJ Kim Elected Governor – Elmbridge Ends November 2017 5/5

Jonathan Quy Elected Governor - Elmbridge Until November 2015 1/2

Jack Saltman Elected Governor – Elmbridge Elected November 2015 to November 2018

3/3

Councillor Christine Elmer

Appointed Governor - Elmbridge Borough Council

Appointed November 2012

3/5

Dr Heather Patel Appointed Governor - Elmbridge - Surrey Downs CCG


2/5

Dennis Doe Elected Governor – Kingston Re-elected November 2015 to November 2018

4/5

Derek Renshaw Elected Governor - Kingston Until November 2015 1/2

Helen Haywood Elected Governor – Kingston Elected November 2015 to November 2018

3/3

Kate Fitzsimmons Elected Governor - Kingston Until November 2015 2/2

Richard Allen Elected Governor – Kingston (Deputy Lead Governor)

Re-elected November 2015 to November 2018

5/5

Robert Markless Elected Governor - Kingston Ends November 2017 5/5

Marita Brown Elected Governor Ends November 2017 5/5

Pat O’Neil Elected Governor Ends November 2017 4/5

Dr Naz Jivani Appointed Governor - Kingston CCG Appointed November 2012

3/5

Councillor Julie Pickering

Appointed Governor – Royal Borough of Kingston upon Thames

Appointed May 2013 3/5

Councillor Margaret Thompson

Appointed Governor – Royal Borough of Kingston upon Thames

Appointed May 2013 4/5

Dr Julia Gale Appointed Governor – Kingston University


3/5

Marilyn Frampton Elected Governor - Merton Ends November 2017 5/5

Dr Sion Gibby Appointed Governor – Merton CCG Representing Merton CCG and Sutton CCG (Joint Nomination)

Appointed January 2014 2/5

Councillor Richard Broadbent

Appointed Governor - London Borough of Sutton Sutton and Merton Borough Councils (Joint Nomination)

Appointed June 2014 4/5

Bonnie Green Elected Governor – Richmond Elected November 2015 to November 2018

2/3


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Frances Kitson Elected Governor – Richmond until November 2015 now Kingston (Lead Governor)

Re-Elected November 2015 to November 2018

5/5

Oana Predescu Elected Governor - Richmond Until November 2015 2/2

Ralph Carter Elected Governor - Richmond Until November 2015 1/2

Lisa Anderton Elected Governor – Richmond Ends November 2017 5/5

Andy Gorton Elected Governor – Richmond Elected November 2015 to November 2018

0/3

Seamus Joyce Elected Governor – Richmond Elected November 2015 to November 2018

1/3

Dr Sean Gallagher Appointed Governor - Richmond CCG Appointed November 2014

0/5

Nicola Urquhart Appointed Governor - London Borough of Richmond


4/5

Paul Hide Elected Governor – Sutton Ends November 2017 3/5

Derrick Young Elected Governor – Wandsworth Ends November 2017 5/5

Dr Fhorkan Uddin Appointed Governor – Wandsworth CCG Appointed December 2013

1/5

Councillor Kim Caddy

Appointed Governor - Wandsworth Borough Council


2/5

Prof Peter Tomkins Elected Governor - Rest of Surrey and Greater London

Ends November 2017 4/5

Alison Tuck Staff Governor – AHP and Clinical Support Staff


2/5

Ursula Kingsley Staff Governor – Management and Administrative Staff

Ends November 2017

4/5

Peter Wilson Staff Governor – Medical and Dental Practitioners


4/5

Sarah Connor Staff Governor – Nursing and Midwifery Ends November 2017 4/5

Meetings of the Council The Council held full meetings on five occasions during 2015-16. In addition to the five formal meetings the Council also participated in a Joint Board and Council of Governors meeting in June 2015 which included discussions on strategy, the second annual joint meeting of the Council of Governors and Non-Executives in March 2016 and governors attended the Annual Members’ Meeting in September 2015. A training and development plan has been developed for the Council of Governors, which includes both external and internal training and engagement. The Council has received training on a number of topics including holding the Board to Account, engagement and the Risk Assurance Framework. In the event of a dispute between the Council of Governors and the Board of Directors, the Council of Governors and the Board of Directors shall meet and attempt to resolve the dispute by negotiation. If agreement cannot be reached then the dispute shall be referred to the Chairman, whose decision shall be final and binding. Register of Governors’ interests A register of Governors’ interests is maintained. A copy of the latest version submitted to the Council of Governors is available on the Trust’s website or it may be inspected during normal office hours at the Chief Executive’s office.


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Involvement with members A Governor Involvement Strategy has been developed and was approved by the Council in March 2014 and revised in March 2016. Governors attend Board meetings and Members’ health talks where they can meet and talk with Trust Members. Members have also attended Healthwatch meetings and have attended Patient-Led Assessment of the Care Environment (PLACE) training. A Membership Recruitment and Engagement Committee, which is a committee of the Council of Governors was established in May 2013. The Committee meets four times a year. Its role is to support the Trust in growing and developing the membership, improving diversity of membership and facilitating communication between Governors, members and the local community. Governors have engaged with patients, members and the wider public in a number of ways during 2015-16. This included:

Monthly email bulletins to members including details of where and how to meet and contact Governors.

Accompanying Executive and Non-Executive Directors on regular Walkabouts and Deep Dive visits.

Regular events such as health talks and tours, with Governors providing a brief welcome talk at the beginning and providing opportunities after the meetings for patients, members and the wider public to speak to a Governor.

Governors regularly attending Trust Board meetings where members can speak to them.

Designated e-mail addresses for Governors by constituency for patients, members and the wider public to contact them.

Governors attending many trust events, both on site such as the Open Day held in June 2015 and off site community events where they have met and recruited members and engaged with the wider public on the work of the Council of Governors and the Trust.

A number of Governors attend their local Healthwatch, CCG and Patient Participation meetings. Membership The Trust first began recruiting members in support of its Foundation Trust application in 2006, and now ten years into the recruitment programme, it has a substantial membership base of 6,956 public members, 398 of which were recruited in 2015-16. The Trust is now targeting the under-represented areas within its membership, to ensure that it has a truly representative membership. Our membership target is to increase our public members by 500 per annum, with a focus on engaging with existing members. The Trust has an extremely high percentage of staff members, with over 99% of staff choosing to remain as members. The Trust acknowledges that to date, the predominant focus of the membership agenda has been on public members and it now wishes to re-dress this imbalance, recognising that it is important to ensure a high degree of engagement and awareness of the membership agenda amongst Trust staff. Community engagement During the year the Trust continued to implement its Membership Engagement Strategy and the Fundraising Strategy to promote good relationships, communication and engagement with the wider community through foundation trust membership, fundraising and some aspects of volunteering. The main aim is to support the Trust in growing and developing the membership, improving diversity of membership and facilitating communication between Governors, Members, Staff and the local community. Throughout the year the Trust has been holding regular members events to engage the membership of the Hospital. We have also been attending local community events around the area to raise awareness of local Governors and use this as an opportunity to recruit new members. In addition, the Trust has been exploring opportunities to forge new links with hard to reach groups such as the Korean and Sri Lankan communities.


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Managing an active membership Specific initiatives are being developed under the Governors’ Involvement Strategy. The types of events the Trust hosts are being extended, and will be scheduled in a way that they appeal to different sub-groups of the membership, providing a mix between the informative Health Talks for members and new initiatives, such as dining companions, and supporting our work with dementia and fund raising activities. Membership catchment map for Kingston Hospital NHS Foundation Trust as at 31st March 2016.

Membership by Constituency

Constituency Members Number of Eligible

population Number of Public

Governors

Elmbridge 889 130,875 2

Kingston 3,047 156,937 8

Merton 439 105,485 1

Rest of Surrey and Greater London 769 8,250,239 2

Richmond 1,346 183,900 3

Sutton 153 41,468 1

Wandsworth 322 136,107 1

Total for all 6,965 9,005,011 18

Further constituency data

Public constituency Last year (2015-2016) Population As at start (April 1) 6,676 New Members 406 Members leaving 117 At year end (March

31) 6,965 9,005,011


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Monitor regulatory ratings For the year 2015-16 Monitor was the regulator for Foundation Trust health services in England. They exercise a range of powers granted by Parliament which include setting and enforcing a framework of rules for providers and commissioners, implemented in part through licences they issue to NHS-funded providers. As part of their role, Monitor has an assessment process which is called a Risk Assessment Framework. The purpose of the framework is to show through a rating system when there may be cause for concern at an NHS foundation trust about financial sustainability or governance. It is important to note that the ratings will not automatically indicate a breach of licence nor trigger regulatory action. Rather, they will prompt Monitor to consider where a more detailed investigation may be necessary to establish the scale and scope of any risk.

The risk rating for the Trust at the end of 2015-16 indicates no evident grounds for concern and that Monitor is not currently undertaking a formal investigation. The table below shows our overall rating for 2015-16 and 2014-15.

In July 2015 Monitor’s opened a formal investigation into the Trust’s compliance with its licence in regards to Cancer, Finance and A&E. In December 2015 Monitor closed the investigation without formal regulatory action, which was replaced by informal monitoring and support to ensure ongoing sustainability in both finance and performance.

Public constituency Number of members Population Index

Age(years):

0 - 16 25 292,096 11

17 - 21 851 492,900 223

22+ 4,051 8,220,015 63

Ethnicity:

White 2,673 5,747,882 60

Mixed 63 412,166 19

Asian 545 1,515,438 46

Black 155 1,053,447 19

Other 79 276,078 36

Socio-economic groupings *:

AB 3,860 1,726,046 289

C1 2,569 2,094,122 158

C2 105 695,447 19

DE 364 1,796,405 26

Gender analysis:

Male 2,395 4,476,964 69

Female 4,342 4,528,047 123


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Table of analysis 2015-16

Annual Plan Q1 Q2 Q3 Q4

CoSR/FSRR

2 2 2 2 2

Governance rating Green Green Under review

Under review

Green

Table of analysis 2014-15


Continuity of service rating

3 3 3 3 3

Governance rating Green/

Amber

Green Green Green Green

Care Quality Commission (CQC) In line with the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Trust continues to be registered with the Care Quality Commission (CQC - the regulator of health and social care in England), without condition, to provide the following services:

Treatment of disease, disorder or injury

Surgical procedure

Diagnostic and screening procedures* **

Maternity and midwifery services

Termination of pregnancies

Family Planning clinics

Assessment or medical treatment for persons detained under the 1983 (Mental Health) Act

* These registered activities include the provision of assisted conception.

**Under South West London Pathology Services, St George’s NHS Foundation Trust, as host organisation,

will provide

Clinical Blood Services (including Blood Transfusion services, which will be retained on the Kingston Hospital site)

Phlebotomy, Anti-coagulation, Mortuary Services and any clinical Pathology (e.g. Clinical Haematology) continue to be provided by Kingston Hospital NHS Foundation Trust.

The Trust also delivers some outpatient clinic activity on the following sites:

Queen Mary's Hospital, Roehampton,

Teddington Memorial Hospital

Molesey Hospital

Cobham Day Surgery Unit

Emberbrook Community Centre

Raynes Park Health Centre

Surbiton Health Centre

Ebbisham Centre, Epsom

Glenlyn Medical Centre

Epsom Cottage Hospital

Leatherhead Community Hospital


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The governance of these clinics is run from the Kingston Hospital site.

In order to maintain registration as a healthcare provider, the Trust is required to demonstrate that it is meeting standards across five domains set out by the CQC:

Safe

Effective

Caring

Responsive

Well led

During 2015-16, the Trust undertook self-assessments of compliance with CQC standards to monitor the safety and quality of services. CQC compliance is considered at the Board to provide assurance.

The Trust was inspected by the CQC on 12-14 January 2016. The Trust is still awaiting the final report.


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Annual Governance Statement

Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum and have carried them out to the best of my knowledge and belief in the context of information made available on handover between Chief Executives during the year. 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 Kingston Hospital NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Kingston Hospital NHS Foundation Trust for the year ended 31 March 2016 and up to the date of approval of the annual report and accounts. Capacity to handle risk Kingston Hospital NHS Foundation Trust is committed to a Risk Management Strategy which minimises risk to all of its stakeholders through a comprehensive system of internal controls, whilst maintaining the potential for flexibility, innovation and best practice in delivery of its strategic objectives around delivering high quality care. The Risk Management Strategy provides a framework for taking this forward through internal controls and procedures which encompass strategic, financial, quality, reputational, compliance and health & safety risks. Its aim is to ensure the safety of patients, staff and the public and to deliver quality, patient-centred services that achieve excellent results and promote the best possible use of public resources, through an integrated approach to managing risks from all sources. The strategy also seeks to support consistency and standardisation through the gathering and dissemination of intelligence on risks and mitigation control measures amongst all staff. The high level Board committee structure discharging overall responsibilities for risk management is summarised below: • Trust Board is responsible for establishing principal strategic and corporate objectives and for

driving the organisation forward to achieve these. It is also responsible for ensuring that effective systems are in place to identify and manage the risks associated with the achievement of these objectives through the Board Assurance Framework and the Corporate Risk Register.

• Audit Committee, on behalf of the Board, reviews the establishment and maintenance of an effective system of internal control and risk management across the whole of the Trust’s activities (both clinical and non-clinical) that supports the achievement of the Trust’s objectives and also ensures effective internal and external audit.

• Quality Assurance Committee (QAC) provides assurance to the Trust Board and Audit Committee that there are adequate controls in place to ensure high quality care is provided to the patients using the services provided by the Trust.

• Finance & Investment Committee (FIC) is responsible for scrutinising aspects of financial performance as requested by the Board, as well as conducting detailed scrutiny of major business cases, proposed investment decisions and regular review of contracts with key partners.


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• Workforce Committee is responsible for providing leadership and oversight for the Trust on workforce issues that support the delivery of the Board’s approved workforce objectives; and for monitoring the operational performance of the Trust in people management, recruitment and retention, and employee wellbeing.

The Risk Management Strategy ensures that risks are identified from the bottom up: the service line accreditation process established risk registers that are managed within each service line and corporate area. Risk identification, assessment and control is carried out locally with accountability through Divisional Directors and quarterly review by the Executive Management Committee. Staff are trained and equipped to manage risk in a way appropriate to their authority and duties through targeted training of individuals and through classroom based options provided internally in the Education Centre. Guidance is provided in writing through the Risk Identification, Assessment and Risk Register Procedure. This includes the process to identify and manage local risks, the systematic means by which these local risks are escalated to Board level attention through the Corporate Risk Register and how risks are controlled and monitored. Further operational procedures for risk and incident management are referenced in the Risk Management Strategy which is available to all staff through the Trust’s policy management system. The Trust also has a Board Assurance Escalation Framework in place which demonstrates how the Trust’s policies, systems and processes work together to provide an effective and robust governance structure enabling the identification of emerging issues and their monitoring, escalation and management at appropriate levels and in a timely way The risk and control framework The Trust understands that healthcare provision and the activities associated with caring for patients, employing staff, providing premises and managing finances will always involve an inherent degree of risk. In broad terms, the groups or areas that may be affected are;

Patients and visitors

Staff (including contractors and volunteers)

Finances

The business of the Trust

Compliance with statutory duties

The Trust’s reputation Key sources of risks are:

Acts or omissions by staff

Information systems and the reports they generate

Trust estate and environmental impact

Actions of contractors

Business continuity i.e. the unexpected failure of a system, which may have a wide impact on delivery of services.

Changes in the external commissioning environment

The key elements of the risk management strategy and the Trust’s approach to risk management identification, evaluation and treatment are summarised as follows.


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Possible risks are identified through a variety of mechanisms, both reactive and proactive. Proactive identification may arise from local risk assessments, impact assessments and gap analyses of published reports on healthcare subjects or inspections of other care providers. Reactive identification can be flagged as a result of a serious incident, a trend in incidents or complaints or as a result of an audit, either internal or external. Risks are analysed, scored, and current controls evaluated according to the Trust’s Risk Identification, Assessment and Risk Register Procedure. The aim of this process is to decide what further action to control the risk is required (treat the risk), or if the risk must be tolerated at its existing level (accept the risk). The key controls used to manage risk are;

Recruitment and training of competent staff

Clarity of accountability and responsibility for all levels of staff

Effective Trust-wide policies

Standard operating procedures for service areas

Governance and risk management systems, such as incident reporting

Performance framework

Capital Investment programme

Working with commissioners and partner organisations Assurance on the effectiveness of these, and other, controls is provided at all levels of the organisation through:

Internal and external audit of control mechanisms

Key Performance Indicators

Benchmarking and Peer reviews

Self-assessment and internal challenge

Service line management and divisional governance and performance management structures The Trust’s definition of a corporate risk is one that meets any of the following criteria:

It is a high level risk that has been scored at ≥ 12.

It is a risk with Trust-wide implications or one that is viewed as Trust-wide.

It is a risk that is deemed to deserve corporate visibility. In developing Service Line Management, the Trust has focused on ensuring that the same standard of risk management seen in the best service lines extends throughout the Trust, including the clinical support and


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corporate areas, and that evidence is recorded to give assurance that risk management is taking place consistently. The Executive Management Committee carries out a quarterly review of the Corporate Risk Register. The Audit Committee reviews the Corporate Risk Register at each meeting and prior to it being received quarterly by the Trust Board. The Trust’s arrangements for quality governance, including how the quality of performance information is assessed and how assurance is obtained routinely on compliance with CQC registration requirements, are based on a robust and systematic approach which permeates right through the organisation and creates and maintains reliable processes and continuous learning. Key elements include:

Quality (and safety) being addressed first on the Board agenda and in a formal quality report. All Board papers highlight their relationship to CQC outcomes.

Utilising the WHO Safe Surgery Checklist to ensure that vital information is conveyed in clinical situations.

Ensuring roles and responsibilities in relation to delivering high quality care are identified in the Governance and Performance Management Frameworks, and using these frameworks to monitor performance and progress.

Capturing patients ideas on improving efficiency and redesign of services.

Implementing NICE quality standards and evidence based guidance

Improving the integration of internal and clinical audit.

Systematic flows of information are from frontline staff to organisational leaders and back, to achieve high reliability and enhance quality.

Assessing the impact of any service development or service change to ensure that the quality and equality of the service or care delivered is not compromised.

The Trust’s IM&T Information Systems Security Policy is designed to ensure that there is a consistent and systematic approach to the management of IT-based Information Assets. This includes the approach to data security, use of password protection and data encryption, prevention of and learning from security breaches, and the corporate policy on system ownership. Compliance with BS 27002 helps ensure that IM&T systems are properly assessed for security, appropriate levels of security maintain the confidentiality; integrity and availability of information and information systems; all staff are aware of their accountability and the limits of their authority; a means is established to communicate awareness of information security issues, their impact on KHFT and other NHS organization’s to management, users and other staff; all electronic data is secured so that only appropriately authorised users may access it. The major risks faced by the Trust, including clinical risks, fall into four broad categories.

Risks arising from deterioration or failure within estates, equipment or core systems that could impact on patient safety or the quality of patient experience.

Risks arising from difficulties in recruiting and retaining the workforce needed and the impact this has on keeping the workforce up to date with core training and skills development.

Risks that impact on the ability to build the relationships needed for a sustainable local health economy.

Financial risks. The Board Assurance Framework is where the Trust Board focuses on ensuring that these risks are mitigated. A monthly report is prepared which tracks how successful the Trust has been in mitigating the risks, whether any further controls are needed or assurance sought. This report is received by the Audit Committee and the Trust Board at each meeting. With regard to the principal risks to compliance with the NHS Foundation Trust condition 4 (FT governance) and actions identified to mitigate these risks during the course of the year, Monitor opened an investigation into Kingston Hospital NHS Foundation Trust in June 2015 due to concerns about financial


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sustainability and performance, the Trust having breached the Accident and Emergency (A&E) four-hour wait target for three consecutive quarters. In December 2015 Monitor closed the investigation without formal regulatory action, which was replaced by informal monitoring and support to ensure ongoing sustainability in both finance and performance. The Trust recognised that turnover within the Board presented a potential risk to the organisation’s ability to address sustainability and performance issues and moved quickly to address turbulence in Board membership during 2015-16. The posts of Chief Executive, Chief Operating Officer and Director of Workforce were covered by interim appointments during the year. The Trust is managing the financial risks through close control of finances, minimising expenditure where possible and ensuring proactive discussions continue to take place with commissioners. Efficiencies identified by Lord Carter are being evaluated and the Trust has taken a realistic and evidence based approach to setting CIP levels for 2016-17. A recovery and transformation plan to enable the Trust to meet the A&E standard was developed with expert support, including from ECIP, and the Trust continues to engage with external partners to find ways to reduce delayed transfers of care. Reports on the impact of these actions have been made to Monitor on a monthly basis. Principal risks to compliance with condition 4 of the Monitor licence around governance were tested during the year through self-assessment against the Monitor Licence and through an independent assessment against Monitor’s Well Led framework for governance. Potential risks to compliance were assessed regularly through the Board Assurance Framework and in work to develop the Quarterly submissions to Monitor, which have been monitored by the Finance & Investment Committee in months in which Board meetings have not taken place. The Board receives performance reports at each formal Board meeting, each Director presenting reports on achievement of targets in relation to their own portfolios in reports on Clinical Quality, Operational Performance, Finance and Workforce. Performance reports are also discussed at Board committee meetings where a ‘deep dive’ approach is taken to gaining additional assurance on any areas of concern. The Trust has an ‘walkabouts’ visit programme, involving Board members and Governors, which includes announced and unannounced visits to wards and teams as a further method of assuring compliance with targets and achievement of objectives. The implementation of the Risk Management Strategy is the principal means by which the Trust is able to assure itself of the validity of its Corporate Governance Statement, required under NHS Foundation Trust Condition 4(8)(b), and is achieved through:

Development and quality assurance of Service Line risk management frameworks to support the Trust’s Risk Management Strategy.

Providing training and support to managers to enable them to manage risk as part of normal line management responsibilities.

Effective use of the governance system and structures in place.

Risk assessments undertaken systematically in all Service Lines and departments to identify risk, assess effectiveness of controls and implement treatment plans, where necessary.

Delivery of action plans at corporate level and at local level, e.g. individual risk treatment plans.

Use of, and compliance with, policies to strengthen the systems of control.

Using information from risk assessment, incidents, complaints, audit, claims and other relevant external sources to improve safety and support organisational learning

Internal and external audits and assessment to provide assurance of the effectiveness of controls to minimise risk.


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Organisational learning and continuous improvement The Trust is committed to continuous improvement, including the sharing of learning from incidents and complaints in an open and transparent culture. The Clinical Quality Improvement Committee leads on the improvement agenda. The Trust’s “Reporting Incidents” and “Identification and Management of Serious Incidents” policies and procedures describe the mechanisms for investigation and learning from incidents. All incidents which meet the criteria for reporting as Serious Incidents (SIs) are investigated by a lead investigator using Root Cause Analysis, and staff have been provided with training to undertake these investigations. Should an incident be categorised as a grade 2 SI, the final report is presented to a Scrutiny Panel which is chaired by a Non-executive director and includes two executive directors, one of whom is either the Medical Director or the Director of Nursing and Patient Experience. The final investigation report is presented to the Board for approval. All SIs are received by the SI Group, which is a sub-committee of the Clinical Quality Improvement Committee, chaired by the Medical Director and escalated as appropriate to Executive Management Committee and/or Trust Board. The Trust Board receives a report on SIs at each meeting. Information and learning from incidents is also triangulated by the Quality Assurance Committee, chaired by a Non-Executive Director. The Quality Strategy describes the role of the Clinical Effectiveness Committee, the annual Clinical Audit Seminar and departmental governance meetings in ensuring the Trust:

Sets challenging goals;

Builds on successes;

Evaluates achievements;

Uses clinical audit to influence improvement processes and targets; and

Shares lessons from quality improvements organisationally, locally and externally. The Trust undertakes reviews of lessons learned from other Trusts to identify areas for improvement. Quality and Equality Impact Assessments (QEIAs) are undertaken for all major schemes, including the Productivity Programme. QEIAs relating to Productivity are escalated via the Clinical Quality Improvement Committee if there are concerns about the impact of a specific scheme. The Trust employs a number of methods to understand the view of public stakeholders in relation to the management of risks which impact upon them and to inform patient experience improvement plans. Executives Directors, Non-Executive Directors and Governors all take part in walkabouts across the Trust, a process which can identify actions to improve patient and staff experience by hearing directly from them and seeing the Trust in operation through their eyes. The Patient Experience Committee leads the Trust’s strategy for delivering excellent patient experience, ensuring there are effective systems to listen to and learn from patients, carers, the public, staff and volunteers. The Trust Board listens to, and considers the lessons from, a patient story at the start of each public board meeting where any further Trust-wide action and communication is agreed. As a Foundation Trust, an established Council of Governors (CoG) was in operation throughout 2015-16, supported by committees focusing on Quality, Strategy, Membership Engagement and Nominations & Remuneration. The CoG receives performance information, including risk assessment framework ratings by Monitor, and the Trust Board and CoG have an annual joint development forum. A Governor Involvement Strategy, approved by the CoG in January 2014, was refreshed in March 2016 to support Governors in gaining assurance as well as interacting with their constituencies; this includes a programme of visits to Trust services including participation in PLACE visits and mock CQC inspections. Delivery of the strategy is led by the CoG’s Membership and Engagement Committee. Detailed


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performance information is also shared at public Board meetings and members of the public in attendance are invited to ask questions of the Board. The Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission. As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The foundation trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. The Emergency Preparedness Group assesses severe weather risks that may result from climate change, using the planning assumptions detailed within national, regional and borough risk registers and where appropriate plans, Trust have been put in place to detail the response to such incidents.

As per the Department of Health heatwave guidance, the Trust operates at level 0 ‘ long term planning’ during the non-heatwave season, which involves year-round joint working to reduce the impact of climate change including planning to keep the built environment cool and energy efficient.

Review of economy, efficiency and effectiveness of the use of resources The Trust ensures economy, efficiency and effectiveness through a variety of means, including:

A robust pay and non-pay budgetary control system

A suite of effective and consistently applied financial controls

Effective tendering procedures

Robust establishment controls

Continuous service and cost improvement and modernisation The Board of Directors performs an integral role in maintaining the system of internal control supported by the Audit Committee as well as internal and external audit. The Trust’s Programme Office Manager oversees the establishment of cost improvement and reconfiguration schemes, to ensure the schemes are realistic, deliverable and have no negative impact on patient care. Information governance During 2015-16 there were six serious incidents relating to information governance and recorded as level 2 incidents. All received Root Cause Analysis Investigation Five of the six were related to email containing patient data being sent unencrypted to the intended recipient. In one of these cases the email was sent in breach of Trust security measures. The Information Commissioner’s Office required no further actions. The final incident involved a clinic letter being placed in the envelope together with a letter for another patient.


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In 2015-16 the Trust received 602 Freedom of Information (FOI) requests. This is ten times the number received in the first year of FOI – 2005. 71.9% of 2015-16 requests were answered within the 20 working day limit due to additional permanent member of staff being assigned. Top subjects include requests for information on IT Infrastructure and Software, Staff Information, Contract Information, Finance and Spend on Bank and Agency Staff. Although the Act is applicant blind we estimate categories and this year the top categories were Members of the Public (which could include the other types under anonymous email accounts), Commercial Enquirers and the Press. 2015-16 also saw the Information Commissioner’s Office Decision Notice on the first complaint to them about a FOI handled by the Trust. The complainant made a freedom of information request to Kingston Hospital NHS foundation Trust for all documents submitted by the winning bidder in a tender for outpatient pharmacy, retail and Homecare services at the Trust. The Trust refused the request under the exemption in section 40(2) (personal information), section 41 (information provided in confidence) and 43(2) (commercial interests) of FOIA. The Commissioner’s decision is that both the section 41 and section 43(2) exemptions are engaged and in the case of section 43(2), the public interest in maintaining the exemption outweighs the public interest in disclosure. The Commissioner requires no steps to be taken. 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 legal requirements in the NHS Foundation Trust Annual Reporting Manual.

The Quality Accounts are reviewed by the Audit Committee following recommendation from the Quality Assurance Committee. The final report is signed off by the Trust Board and published on the Trust website and NHS Choices by 30 June 2016.

In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:

The Quality Account presents a balanced picture of the Trust’s performance over the period covered.

The performance information reported in the Quality Account is reliable and accurate.

There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice.

The data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review.

The Quality Account has been prepared in accordance with Department of Health guidance.

The Directors are required to confirm compliance with these requirements in a statement of directors’ responsibilities within the Quality Account. The Chairman and Chief Executive formally sign the final report at the May Trust Board prior to publication.

External auditors conduct a review under limited assurance. The limited assurance engagement is narrower 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. This leads to a limited assurance statement having conducted the following assessments:

• Board minutes for the period 1 April 2015 to 19th May 2016 • Papers relating to quality reported to the Board over the period 1 April 2015 to 19th May 2016 • Feedback from Commissioners dated 20/05/16; • Feedback from Governors dated 19/05/16; • Feedback from local Healthwatch organisations dated 20/05/16;


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• Feedback from Overview and Scrutiny Committee dated 20/05/16; • The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 14 April 2016; • The national patient survey dated 2015; • The national staff survey dated 22/03/2016; • Care Quality Commission Intelligent Monitoring Report dated 28/05/2015; • The Head of Internal Audit’s annual opinion over the Trust’s control environment; and • Any other information obtained during our limited assurance engagement. A long list of potential quality priorities was developed in consultation with stakeholders such as Healthwatch, Trust committees, commissioners and Governors. Giving stakeholders a wide range of opportunities to engage with the Trust on the quality priorities ensures fair and balanced selection and that the priorities are pertinent to the needs of all stakeholder groups.

The dates of consultation are listed below:

Clinical Quality Improvement Committee 7 October 2015

Governors Quality Scrutiny Committee 16 December 2015

Quality Assurance Committee 6 January 2016

Council of Governors 21 January 2016

Trust Board meeting (public) 27 January 2016

Kingston Hospital Monthly team brief document 5 February 2016

Healthwatch Forum 10 February 2016

Clinical Quality Review Group 16 March 2016

The quality priorities long list was then put to a public vote during February 2016. Staff, volunteers, Trust members and the public were asked to vote on which priorities to select from the long list. Three priorities were voted for from each domain: patient safety, clinical effectiveness and patient experience. The priorities with the most votes were selected as the nine Trust Quality priorities for 2016-17. A total of 304 people completed the quality priorities survey. The results of the survey were combined with feedback from various committees and forums, as well as current Quality Improvement Projects, the Sign up to Safety projects and the draft Annual Plan 2016-17.

The Director of Nursing & Patient Experience presented an updates on the development of the Quality Account to the Quality Assurance Group on 6 January and 11 May 2016. He outlined the process so far, which included engagement with the Council of Governors, Clinical Quality Review Group and Quality Scrutiny Improvement Group.

The Council of Governors has been advised which two mandated performance indicators and one selected by governors are to be reviewed by external audit for provision of a limited assurance report; the mandated indicators are:

· percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period

· percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge

The Council of Governors has agreed which local indicator should be reviewed in line with requirement and this will also be reviewed; the external audit report will not provide a limited assurance report but will report findings in the report to the governors on the Quality Account. The Governors have agreed that the third national indicator should be used:

total number of complaints reported by financial year


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The data for the Quality Account is derived from the Clinical Quality Report. This report was initially designed following a consultation exercise with Deloitte and the content of the report was agreed with the Board. This process is now repeated internally on an annual basis.

Each data indicator has ownership from an Executive Director who reviews the data and signs off the report before it goes to the Board. Exception reports are used to provide more detail to the Board on areas of concern. Changes to the Reports are recorded in a change log so that there is an audit trail if a decision is made to remove or amend an indicator.

The Business Intelligence team co-ordinates the collection of all data for the report. They hold a glossary of all indicators which states the data source, executive owner, target/benchmark and criteria for an exception report. Data for all Trust Performance Reports is held in one location to ensure consistency across all reports and to reduce the chance of transcription errors. There is a comprehensive set of validation and quality assurance reports which are reviewed on a weekly basis with individual service lines.

Other sections of the report mandated required data from the Health and Social Care Information Centre, Financial Reports (CQUIN), Information Governance Toolkit, National Clinical Audits and National Confidential Inquiries.

Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the NHS foundation trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. In February 2015, the Board undertook a self-assessment exercise against Monitor’s Well Led Framework and developed an action plan to address gaps. During 2015-16, as part of its development activity, the Board reviewed progress against this action plan and assessed the Trust’s compliance with the Monitor Licence requirements. The Trust commissioned Capsticks Consultancy Service to carry out an external review of governance, as required every three years under Monitor’s risk assessment framework. The review was undertaken between September and December 2015 and is the first external review since the Trust was granted Foundation Trust status in May 2013. Capsticks were selected by competitive tender process and it was confirmed as part of that process that they have no other connection to the Trust. The key overall findings were that governance processes and structures are sound and appear to be working well, including those relating to performance management. Each of the Board’s committees also carried out a review of its own effectiveness as part of its annual work plan.

A comprehensive performance appraisal process is in place for the Directors and the Chairman. 360° feedback is sought anonymously for each Director from other Board members, governors and, for the Chairman, from external stakeholders. An annual appraisal meeting takes place for each Director led by the Chairman for Non-Executive Directors, the Chief Executive for Executive Directors and the Senior Independent Director for the Chairman. Appraisal is undertaken against personal objectives set annually and a six month review is carried out to assess progress mid-year. Personal objectives are aligned to the strategic objectives of the Trust. The Nominations & Remuneration Committee oversees the process for Non-Executive Directors, reporting to the Council of Governors, and the Remuneration Committee, reporting to the Board, oversees the process for Executives.


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The Head of Internal Audit provides me with an opinion on the overall arrangements for gaining assurance through the Board Assurance Framework and on the controls reviewed as part of internal audit’s work. The Head of Internal Audit for the Financial Year 2015-16 gave substantial assurance that there is a generally sound system of internal control on key financial and management processes. These are designed to meet the Trust’s objectives, and controls are generally being applied consistently. During 2015-16 KPMG provided internal audit services. The contract and associated Quality Plan specify that the delivery of internal audit function will continue to be in compliance with NHS Internal Audit Standards and those of the Institute of Internal Auditors (UK).

The following major sources of external assurance were received in 2015-16, either as commissioned reports or other externally activity not commissioned by the Trust:

Commissioned (Internal Audit Reports) and outcomes

Review Assurance Level

Safeguarding Adults at Risk Significant assurance with minor improvement opportunities

Governor Effectiveness Dashboard Significant assurance with minor improvement opportunities

Core Financial Systems Significant assurance with minor improvement opportunities

Financial Reporting Significant assurance with minor improvement opportunities

Dissemination of Guidance Significant assurance

Duty of Candour Partial assurance with improvements required

Data Quality Significant assurance with minor improvement opportunities

Service Line Management To be confirmed

Not commissioned External Visits – Annual Report 2015-16

April 2015

The Health & Safety Executive reviewed the management process of needle stick. No breaches were identified. Seven minor recommendations were made; an action plan to address them has been developed and is being progressed.

May 2015

PLACE (Patient-led Assessment of the Care Environment visit) - the Cleaning mostly maintained the high quality observed on previous PLACE assessments. The Condition and Appearance was better in the internal public areas (corridors, entrances) than previously and the rest was the same mix of good quality and room for improvement as before. Privacy, Dignity and Wellbeing has scored well in the past and we expect this to be maintained. The food was praised by the teams and showed a significant improvement over last year; this reflects the work carried out over the last 12 months.

The Dementia Environment element was scored this year and the score will represent our current situation with minimal environmental adaptations made. This will act as a baseline for future progress.

July 2015

Human Tissue Authority - Inspection RE: HTA licence to perform post mortem examinations subject to conditions set by the HTA. Licence retained.

Royal Eye Unit & Specialist Service Division - The RNIB and the Thomas Pocklington Trust offered advice and training to staff on improving accessibility for people with visual impairment. Healthwatch Kingston undertook mini surveys and interviews with patients who access the Royal Eye Unit and Day Surgery in order to capture and improve on patient experience.


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Monitor visited the Trust to investigate finances and performance in A&E. The investigation was later closed with no regulatory action required.

August 2015

Emergency Care Intensive Support Team (ECIST) – to look at our improvement plans for patient flow across the urgent care pathway

CQC – the CQC visited A&E and a number of other areas for assurance on provision of high quality patient-centred responsive and safe care.

NHS England – field visit focused on Cancer Services reviewing performance and identifying gasp for improvement.

Monitor – Reviewed KHFT annual plans as part of its investigation into finances.

September 2015

Alzheimer’s Society Trustees visited to find out more about dementia care at KH, to acquaint the Trust Board with the people and policy landscape around the hospital and to foster a partnership with the aim of improving the quality care for dementia patients and raising it awareness and profile.

National Peer Review Programme – To assess compliance against the Cancer Standard Measures and to assess that KH were functioning as a joint MDT in a cohesive manner

October 2015

The Royal College of Anaesthetist Accreditation Standard – Assessment visit in order for the service to be recognised as an accredited service. SL has now been accredited.

Church of England Kingston – Attended the licensing of the Hospital’s new Lead Chaplain, The Reverend Susan van Beveren

DH Connecting Programme visited partly in response to the Francis Inquiry into Mid-Staffordshire. Members of the DH team engaged with patients and service user in order to capture their experience of receiving care at KH.

CCGs & Community Partners – meeting with partners from the CCGs and Community Team to find suitable accommodation for 24 patients who could not be discharged because community beds and care had not been agreed.

The London Fire Brigade – to assess if the Trust was compliant with relevant Fires and Safety Requirements.

November 2015

HFEA (Human fertilisation and embryology authority) – Inspection December 2015

Kingston Healthwatch – 5 visits have taken place with this being the final one.

Health & Overview Panel Councillors visited A&E and AAU.

January 2016

The London Quality Assurance Reference Centre – Audit related to Colposcopy & Histology

Public Health England – The NHS Cancer Screening – Inspection to ensure that the Trust was meeting its cancer performance

CQC Inspection – Routine inspection

London Stroke Network routine Inspection - Overall the quality of care that patients receive from the stroke team at KHFT is very good. There were several issues that were raised and these are currently being addressed

March 2016

The London Fire Brigade – routine inspection – no actions required

UK Accreditation Service – Audiology - Accredited


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Participation in Clinical Audits Clinical audit is designed to improve patient care, treatment and outcomes. Its purpose is to involve all

healthcare professionals in a systematic evaluation of delivery of care against evidence based standards,

identify actions to improve the quality of care and deliver better care and outcomes for patients. The work

carried out by the various National Confidential Enquiries involves review of patient care nationally. The

resulting recommendations enable local hospitals to drive up standards and enhance patient care and

safety.

At the start of 2015/16, 36 national clinical audits and 3 national confidential enquiry programmes covered

NHS services that Kingston Hospital NHS Trust provides. During that period Kingston Hospital NHS Trust

participated in 89% (32/36) national clinical audits that have started to date and 100% per cent of national

confidential enquiry programmes of the national clinical audits and national confidential enquiry

programmes which it was eligible to participate in.

The national clinical audits and national confidential enquiries that Kingston Hospital NHS Trust was eligible

to participate in during 2015/16 and for which the data collection was completed during 2015/16, are listed

in Appendix 2 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.

The reports of 23 national clinical audits, applicable to Kingston Hospital, were published during 2015/16

and of these 17 were formally reviewed during 2015/16 (the remainder awaiting review). The actions we

intend to take to improve the quality of healthcare are included in the Quality Account.

The reports of 150 local clinical audits were reviewed by Kingston Hospital NHS Foundation Trust in

2015/16. Examples of improvement actions taken as a result of national and local audit are shown in the

table below.

Clinical audit results are discussed at clinical meetings in local departments and at wider meetings such as

the Trust’s annual Clinical Audit Seminar. The results of both national and local clinical audits are used to

drive local quality improvement. More detailed information about the actions we have taken from clinical

audit will be available in our Clinical Audit and Effectiveness Annual Report, via the Medical Director’s

department, from July 2016.

National and local clinical audit results are used by Kingston Hospital to both assure itself of the quality of

patient care and improve care where gaps are found. Four examples of how clinical audit results have

provided assurance and improved care during 2015/16 are given in the boxes below.

Clinical audit providing assurance

National audit The Trust has taken part in the National Bowel Cancer Audit for a number of years and the most recent report published in December 2015 contained results for 138 Kingston patients with comparisons to the national average. Kingston’s two year mortality rates (observed and adjusted) were both well below the national average of 22%, at 15% and 16.9% respectively. Our 90 day readmission rate was also much lower than the national average, with our adjusted rate 12.4% compared to the national average rate of 19.9%. The national audit data is reviewed regularly throughout the year by the Colorectal team.

Local clinical audit Whilst the prescribing of drugs is usually within the remit of a doctor, a number of Kingston Hospital’s nursing staff are able to prescribe drugs, having undertaken and passed a prescribing course. To ensure that this prescribing is carried out safely, a peer review audit was conducted by the nurses themselves during 2015 of over 100 prescriptions. The prescriptions were assessed for the type of drug prescribed, its dose, frequency and duration. The audit found that all nurse prescribers were prescribing within their capacities to a high standard, with good record keeping demonstrated.


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Clinical audit driving improvement

National audit Clinical data submitted to the National Emergency Laparotomy Audit has been used at Kingston by clinicians from Anaesthetics, Surgery and ITU to make substantial improvements to patient care over the past year. This involved the implementation of a clear care pathway for patients undergoing emergency laparotomy surgery, including increased consultant input and admission post operatively to ITU, as well as the appointment of new Elderly Care doctors for Surgery to ensure timely patient assessment. The 30 day mortality rate for Kingston hospital in 2015 was 5.9% compared to the national average of 11%.

Local clinical audit Handover of care between wards is very important for patient care, both in terms of safely and patient progress. The post natal wards have used local clinical audit to drive improvement over the past year in raising standards in patient handover. They performed audits monthly against the hospital’s guideline on Handover of Care to track progress, increasing their use of the SBAR tool (Situation, Background, Assessment, Recommendation). Improvements were made through staff training and engagement.

Standing Orders, Scheme of Delegation and Standing Financial Instructions The three key documents setting out the Trust’s Governance arrangements are the Standing Orders, the Scheme of Delegation (and reservation of powers) and the Standing Financial Instructions.

The Trust’s Standing Orders set out the framework under which the Trust established, the requirement for Audit and Remuneration Committees, the procedures under which the Board operates and other key governance mechanisms for the Trust. The Standing Orders have followed Department of Health Guidance and have been updated and reviewed each year. These are subsumed into the constitution of the Foundation Trust.

The Scheme of reservation and delegation sets out the framework for delegating (or not delegating) decisions within the organisation. These are also reviewed annually.

The Standing Financial Instructions (SFIs) set out the detailed operation of the Trust’s financial systems and are designed to ensure that the Board has appropriate control of the financial systems and mechanisms in the organisation and that there is proper monitoring and use of financial resources. The SFIs are reviewed annually by both the Audit Committee and the full Board.

Role and Conclusions of key Board committees in 2015-16

Audit Committee

The Audit Committee is responsible for oversight and assurance that processes undertaken by the Trust Board and other committees are operating effectively. In fulfilling its role the Committee:

Reviews the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the Trust’s activities (both clinical and non-clinical), that supports the achievement of the Trust’s objectives.

Advises the Board on internal and external audit services.

Monitors compliance with standing orders and standing financial instructions.

Reviews schedules of losses and special payments.

Reviews the annual financial statements prior to submission to the Board.

Reviews the Quality Account following recommendation from the Quality Assurance Committee.

Reviews findings of significant assurance functions, both internal and external.

The Committee’s main activities during the course of the year have been:

Consideration of Internal Audit Reports

Approval and monitoring of progress with the Internal Audit and Counter Fraud plans

Quarterly reports from the Head of Clinical Audit and Effectiveness


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The Committee has provided reports to Board meetings after each of its meetings and through that process identified areas it wished to draw to the Board’s attention. The Committee undertook its annual self-assessment in September 2015. Finance and Investment Committee The role of the Finance and Investment Committee is to scrutinise financial planning and performance, review any areas of concern and report them to the Board. It carries out detailed scrutiny of major business cases and proposed investment decisions on behalf of the Board, oversees major projects and regularly reviews contracts with key partners. Regular reports have been received and reviewed by the Committee in the following areas:

Discussion of the financial performance of the previous month and forecast for the year

Update on debtors, creditors and cash

Productivity update

Review of performance against the current contract and update on negotiations for next year’s contract

Review of the performance of the Trust’s joint ventures (BMI, Royal Marsden, Prime)

Sign off of quarterly Monitor returns

Discussion of Monitor updates / bulletins, KPMG Economic updates and Grant Thornton technical updates

The Committee has provided reports to Board meetings after each of its meetings, identifying areas it wished to draw to the Board’s attention. The Committee undertook its annual review of its terms of reference (ToR) and effectiveness in October 2015.

Quality Assurance Committee

The approved terms of reference of the Quality Assurance Committee are to:

Scrutinise the assessment of quality risks identified in the Board Assurance Framework as detailed on the Corporate Risk Register and ensure there is sufficient assurance that these risks are managed by the Trust, including actions to eliminate gaps in controls, for example, ensuring that audit programmes address the key issues.

Review the performance of the Trust in meeting its relevant statutory and regulatory obligations including compliance with the NHS Act 2006, the Health and Social Care Act 2008 (and its successor documents) and the CQC (Registration) Regulations 2009 (and its successor documents).

Review the evidence to support the Trust’s Quality Governance arrangements.

Monitor and review the Trust’s Quality Performance Indicators in relation to quality and safety. The QAC will work with the Clinical Quality Improvement Committee (CQIC) to identify the most valuable quality indicators for the Board and maintain oversight of the clinical quality aspects of CQIC’s work to ensure it has appropriate quality monitoring mechanisms in place for all levels of the organisation.

Seek assurances at least annually from management that lessons are being learnt and relevant changes made following incidents, including SIs, complaints and claims.

Review the corporate risk register (in accordance with Risk Management Strategy) seeking assurance that clinical quality risks are accurately reflected and that appropriate action plans are in place to mitigate the risks.

Monitor the Trust’s compliance with the CQC’s Essential Standards of Quality and Safety.

Monitor and make recommendations on the adequacy and effectiveness of any aspects of the Trust’s performance as the Board may request, focusing mainly but not exclusively on outcome measures and liaising with the Finance and Investment and Audit Committees to minimise duplication.

Maintain oversight of quality related strategies.


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Review the Quality Report elements of regular Monitor submissions prior to endorsement of the Quarterly Reports and statements by the Board of Directors before submission to Monitor, where required.

Review and approve the annual Clinical Audit Programme. The Committee will commission audits from clinical audit or internal audit (as appropriate) as and when it requires in year if a risk is identified which requires more focus and increased assurance.

Review the draft Trust Quality Account prior to adoption by the Trust Board.

Seek assurances from the Complaints Committee on the concerns raised in the complaints received by the Trust and reviewed by the Committee.

In order to enable patients to take a stronger role in influencing the quality agenda, a Governors’ Quality Scrutiny Improvement Group is in place. The group is attended by the Chair of the Quality Assurance Committee.

The Quality Assurance Committee’s main activities during 2015-16 were:

Deep Dives

Review of the Clinical Audit programme

Review of quality risks on the CRR

Development of the Quality Account

Quality Strategy update

Clinical Audit quarterly reports and annual report

Quality improvement projects

Quality KPIs and Ward scorecard

Review of progress against the Risk Management Strategy objectives The Committee has provided reports to Board meetings after each of its meetings and through that process identified areas it wished to draw to the Board’s attention. Staff concerns and actions

The Committee undertook its annual self-assessment in May 2015. Conclusion No significant internal control issues have been identified as a result of my review of the effectiveness of the system of internal control.

Ann Radmore Chief Executive 23rd May 2016


84

Appendices

Quality Report 2015-16

Working together to deliver exceptional

compassionate care, each and every time

of 100 Quality Report version 7 May 2016

Pictures on front cover (clockwise)

Midwife of year winner (top left)

Therapy dog in action (top right)

Dementia activities session (bottom centre)


Contents

Part 1

1. Introduction from the Chief Executive 6

2. What is a Quality Report? 8

- Scope and structure of the Quality Report

3. Language and Terminology 9

Part 2

4. Kingston Hospital NHS Foundation Trust Priorities for 2016/17 13

Domain: Patient Safety 17

Priority 1 - Reduce falls in the hospital setting.

Priority 2 - Reduce avoidable harm from sepsis.

Priority 3 - Reduce use of agency staff by reducing vacancies.

Domain: Clinical Effectiveness 21

Priority 4 - Reduce readmissions in non-elective care.

Priority 5 - Reduce length of stay.

Priority 6 - Reduce patient reported pain.

Domain: Patient Experience 24

Priority 7 - Transform administration across the hospital.

Priority 8 - Improve end of life care.

Priority 9 - Improve patient experience of discharge.


Part 3

5. Looking Back at 2015/16 28

Domain: Patient Safety 29

Priority 1 - Improved recognition and management of sepsis in hospital

Priority 2 - Implement patient safety elements of Year 2 of the Dementia Strategy

Priority 3 - Reduce use of agency staff by reducing vacancies

Domain: Clinical Effectiveness 36

Priority 4 - Work towards paper-light systems using information technology and

record management across the Trust

Priority 5 - Ensure all staff are up to date with core (mandatory) training, have clear

objectives, regular appraisal and a personal development plan reflecting our values

Priority 6 –Increase the provision of 7 day working of key staff and services

Domain: Patient Experience 42

Priority 7 - Transform administration across the hospital and make improvements in

administration

Priority 8- Improve patients’ and their relatives’ experience of End of Life Care

Priority 9 - Improved discharge planning and processes

6. Other Improvements to Quality of Care at Kingston Hospital 48 7. Overview of Services 62

8. Monitor Risk Assessment Framework 63

9. Participation in Clinical Audits 65

10. Participation in Clinical Research 66

11. Use of the CQUIN Payment Framework 67

12. Care Quality Commission (CQC) Registration 70

13. Data Quality 72

14. Clinical Coding 73

15. Information Governance Toolkit Attainment Levels 74

16. National Data from the Health and Social Care Information Centre 75

17. Independent Auditors’ Limited Assurance Report to the Directors of Kingston

Hospital NHS Foundation Trust on the Quality Report 82


Appendix 1 National Confidential Enquiries 85

Appendix 2 Eligible National Clinical Audits 2014/15 – Participation rates 86

Appendix 3 Actions to be taken following completed national clinical audits 88

Annexe 1 Stakeholder Feedback 90

Annexe 2 Statement of Directors’ Responsibilities in respect of the Quality Report 98


Part 1

Quality Report 2015/16

1.0 Introduction from the Chief Executive

Quality is very much at the heart of everything we do at Kingston Hospital and I am proud of the

many improvements we have made for our patients. These improvements have helped us to

provide better care and experience for our patients and made them safer. This report is a review of

how we have performed during 2015-16 and looks forward to what our quality priorities will be

during 2016-17.

Over the last year we have seen over 113,000 patients in A&E, undertook nearly 390,000 outpatient

appointments, cared for 31,000 admitted patients and delivered around 5,800 babies. All of our

quality priorities support the care and treatment provided to all our patients.

We agreed on nine ambitious quality priorities for 2015-16 and we have achieved five and part

achieved four. One of our effectiveness priorities was to increase the amount of time nurses have

available to spend with patients by introducing electronic recording of vital signs. The initial roll out

of new technology to record blood pressure and temperature automatically into the patient record

has been a huge success and in one month 225 hours of nursing time has been released as a result of

using this technology.

We also achieved the priority of improving the provision of seven day working in the Trust and to

improve the achievement of the London Quality Standards. During 2015-16 the Trust made some

essential investments in quality and reviewed the staffing structures. The improvements include the

recruitment of three Emergency Surgeons to deliver improved emergency services; Recruited

additional paediatric consultants to ensure presence between 8am and 10pm.

Providing the best End of Life care possible is a commitment of the Trust and the last year we

achieved the quality priority of improve patients’ and their relatives’ experience of End of Life care.

In a survey carers and patients reported having a better experience than the national average. for

nurses and doctors having time to listen and discuss their condition. More people than the national

average said they had confidence and trust all the time in the doctors caring for them and more

people felt very involved with decisions about their care and treatment compared to the national

picture.

Dementia care has continued to be focus for the whole Trust and I am particularly proud of the work

being done to improve the care provided and also the lives of our patients with dementia. There are

many elements to the work and it includes transforming the environment on our elderly care wards

and providing therapeutic activities and support. During 2016-17 Derwent, one of our elderly care


wards, will be transformed into a dementia friendly environment and work will continue to

implement the Dementia Strategy.

Sepsis is a national priority and at Kingston we have focussed a great deal of attention on making

sure we recognise and treat patients with sepsis at the earliest opportunity. Recognition and

management of sepsis is one of the Trust’s ‘Sign up to Safety’ projects and we have a three year

improvement project plan to ensure that we continue to see sustained improvements.

For the last few years we have worked hard to involve staff, the local community, partners and

stakeholders in decisions about our services and priorities for improvement and always listen to the

feedback we receive when things have gone well and when we could have done better. We have

involved them in helping to set our priorities for 2016-17, which are:

Domain Priority

Patient Safety

- Reduce falls in hospital setting - Reduce avoidable harm from sepsis - Reduce use of agency staff by reducing vacancies

Clinical Effectiveness

- Reduce readmissions in non-elective care - Reduce length of stay - Reduce patient reported pain

Patient Experience

- Transform administration across the hospital - Improve end of life care - Improve patient experience of discharge

The Quality Report presents a balanced picture of the Trust’s performance over the period covered

and to the best of my knowledge the information reported in the Quality Report is reliable and

accurate.

Ann Radmore Chief Executive 23rd May 2016


2.0 What is a Quality Report?

All providers of NHS services in England have a statutory duty to produce an annual report to the public about the quality of services they deliver. This is called the Quality Report. Quality Reports aim to increase public accountability and drive quality improvement within NHS organisations. They do this by getting organisations to review their performance over the previous year, identify areas for improvement, and publish that information, along with a commitment to you about how those improvements will be made and monitored over the next year.

Kingston Hospital NHS Foundation Trust focuses on three areas that help us to deliver high quality services:

Patient safety

How well the care provided works (clinical effectiveness)

How patients experience the care they receive (patient experience)

Some of the information in a Quality Report is mandatory but most is decided by patients and carers, Foundation Trust Governors, staff, commissioners, regulators and our partner organisations.

2.1 Scope and structure of the Quality Report

This report summarises how well we did against the quality priorities and goals we set ourselves for the last year and if we have not achieved what we set out to do, we have explained why and what we are going to do to make improvements. It also sets out the priorities we have agreed for the coming year and how we intend to achieve them and track progress throughout the year.

One of the most important parts of reviewing quality and setting quality priorities is to seek the views of our patients, staff and key stakeholders (such as the Clinical Commissioning Groups, Council of Governors, Healthwatch Groups). The Quality Report includes statements of assurance relating to the quality of services and describes how we review them, including information and data quality. It also includes a description of audits we have undertaken, our research work, how our staff contribute to quality and comments from our external stakeholders.

If you or someone you know needs help understanding this report, or would like the information in another format, such as large print, easy read, audio or Braille, or in another language, please contact our Communications Department. If you have any feedback or suggestions on how we might improve our Quality Report, please do let us know either by emailing:

Duncan Burton, Director of Nursing and Patient Experience at [email protected] or Lisa Ward, Head of Communications at [email protected] or in writing to our Patient Advice Liaison Service (PALS) at: Kingston Hospital NHS Foundation Trust, Galsworthy Road, Kingston upon Thames, Surrey, KT2 7QB.

mailto:[email protected]

mailto:[email protected]


3.0 Language and Terminology

It is very easy for people who work in the NHS to assume that everyone else understands the language that we use in the course of our day to day work. We use technical words to describe things and also use abbreviations, but we don’t always consider that people who don’t regularly use our services might need some help. In this section we have provided explanations for some of the common words or phrases we use in this report.

Admission: There are three types of admission:

Elective admission: A patient admitted for a planned procedure or operation

Non-Elective (or emergency) admission: A patient admitted as an emergency

Re-admission: A patient readmitted into hospital within 28 days of discharge from a previous hospital stay

Benchmarking: Benchmarking is the process of comparing our processes and performance measures to the best performing hospitals, or best practices, from other hospitals. The things which are typically measured are quality, time and cost. In the process of best practice benchmarking, we identify the other Trusts both nationally and/ or locally and compare the results of those studied to our own results and processes. In this way, we learn how well we perform in comparison to other hospitals. Care Quality Commission (CQC): The CQC is the independent regulator of health, mental health and adult social care services across England. Its responsibilities include the registration, review and inspection of services and its primary aim is to ensure that quality and safety standards are met on behalf of patients. Care Records Service (CRS): The NHS has introduced the NHS Care Records Service (NHS CRS) throughout England and Wales. This is to improve the safety and quality of your care. The purpose of the NHS Care Record Service is to allow information about you to be safely and securely accessed more quickly. Gradually, this will phase out difficult to access paper and film records. There are two elements to your patient records:

Summary Care Records (SCR) - held nationally

Detailed Care Records (DCR) - held locally CHKS: Data provider used by the hospital for benchmarking and performance information.

Shows local and national data for a range of performance, safety and quality indicators.

Clostridium Difficile (C diff): Clostridium Difficile is a bacterium that is present naturally in the gut of around 3% of adults and 66% of children. It does not cause any problems in healthy people. However, some antibiotics that are used to treat other health conditions can interfere with the balance of 'good' bacteria in the gut. When this happens, C diff bacteria can multiply and cause symptoms such as diarrhoea and fever.

CQUIN: A CQUIN (Commissioning for Quality and Innovation) is payment framework that enables commissioners to reward excellence, by linking a proportion of the hospital’s income to the achievement of local quality improvement goals.. Day case: A patient admitted electively (i.e. from a waiting list) during the course of a day with the intention of receiving care without requiring the use of a hospital bed overnight. Delayed Transfer of Care (DTOC): Delay that occurs once the Multi Disciplinary Team have decided the patient is medically fit for discharge and it is safe to do so.


End of Life Care: Support for people who are approaching death Foundation Trust: NHS Foundation Trusts in England have been created to devolve decision-making to local organisations and communities so that they are more responsive to the needs and wishes of local people.

Friends and Family Test: This is a survey which asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care.

Healthcare Associated Infections (HCAI): Healthcare associated infections are infections that are acquired in Hospitals or as a result of healthcare interventions. There are a number of factors that can increase the risk of acquiring an infection, but high standards of infection control practice minimise the risk of occurrence.

Information Governance (IG) Toolkit: The IG Toolkit is an online system which allows NHS organisations and partners to assess themselves against Department of Health Information Governance policies and standards. It also allows members of the public to view participating organisations' IG Toolkit assessments.

Inpatient: A patient admitted with the expectation that they will remain in hospital for at least one night. If the patient does not stay overnight after all they are still classed as an inpatient.

Methicillin Resistant Staphylococcus Aureus (MRSA): It is a bacterium from the Staphylococcus aureus family. MRSA bacteria are resistant to some of the antibiotics that are commonly used to treat infection, including methicillin (a type of penicillin originally created to treat Staphylococcus aureus (SA) infections).

Mortality: Mortality rate is a measure of the number of deaths in a given population

The National Institute for Health and Care Excellence (NICE): provides national guidance and advice to improve health and social care. NICE's role is to improve outcomes for people using the NHS and other public health and social care services. Their main activities are:

•Producing evidence based guidance and advice for health, public health and social care

practitioners.

•Developing quality standards and performance metrics for those providing and

commissioning health, public health and social care services.

•Providing a range of informational services for commissioners, practitioners and managers

across the spectrum of health and social care

Outpatient: An attendance at which a patient is seen and the patient does not use a hospital bed for recovery purposes.

Patient Falls: Patients of all ages fall. Falls are most likely to occur in older patients, and they are much more likely to experience serious injury. The causes of falls are complex and older hospital patients are particularly likely to be vulnerable to falling through medical conditions including delirium (acute confusion), side effects from medication, or problems with their balance, strength or mobility. Problems like poor eyesight or poor memory can create a greater risk of falls when someone is out of their normal environment on a hospital ward, as they are less able to spot and avoid any hazards.


Patient Safety Incident: A patient safety incident is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care.

Pressure Ulcers: Pressure ulcers are a type of injury that breaks down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They are also sometimes known as 'bedsores' or 'pressure sores'. Pressure ulcers can range in severity from patches of discoloured skin to open wounds that expose bone or muscle.

Risk Adjusted Mortality Index: Hospital mortality rates refer to the percentage of patients who die while in the hospital. Mortality rates are calculated by dividing the number of deaths among hospital patients with a specific medical condition or procedure by the total number of patients admitted for that same medical condition or procedure. This risk adjustment method is used to account for the impact of individual risk factors such as age, severity of illness and other medical problems that can put some patients at greater risk of death than others. To calculate the risk-adjusted expected mortality rate (the mortality rate we would expect given the risk factors of the admitted patients), statisticians use data from a large pool of patients with similar diagnoses and risk factors to calculate what the expected mortality would be for that group of patients. These data are obtained from national patient records.

Sepsis Six (6): The Sepsis Six is the name given to a bundle of medical therapies designed to reduce the mortality of patients with sepsis. A training programme became the official educational package of both the Surviving Sepsis Campaign and the UK Sepsis Trust. The Sepsis Six consists of three diagnostic and three therapeutic steps – all to be delivered within one hour of the initial diagnosis of sepsis. Many centres throughout the world have since adopted the Sepsis Six, which has been associated with decreased mortality, decreased length of stay in hospital, and fewer intensive care bed days

Serious Incident Group (SIG): The SIG membership includes Divisional Clinical Directors and Corporate Directors, as well as, Risk Managers, a representative from the Kingston Clinical Commissioning Group (CCG) and is chaired by the Medical Director. The group ensures that comprehensive serious incident investigations take place within the Trust, and that appropriate recommendations and robust actions are identified and delivered. Thus ensuring learning from incidents to improve both the quality of patient care.

Sign up to Safety: Sign up to Safety is a national patient safety campaign that launched in June 2014 with the mission to strengthen patient safety in the NHS and make it the safest healthcare system in the world.

As part of signing up to the Sign up to Safety campaign organisations commit to setting out

actions they will undertake in response to the following five pledges:

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

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

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

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

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


The Standardised Hospital Mortality Index (SHMI): SHMI gives an indication for each non-specialist acute NHS trust in England whether the observed number of deaths within 30 days of discharge from hospital is 'higher than expected', 'lower than expected' or 'as expected' when compared to the national baseline. A 'higher than expected' SHMI value should not immediately be interpreted as indicating good or bad performance and instead should be viewed as a 'smoke alarm' which requires further investigation by the trust. The SHMI can be used by trusts to compare their mortality related outcomes to the national baseline. However, it should not be used to directly compare mortality related outcomes between trusts and it is not appropriate to rank trusts according to their SHMI value.

Venous Thrombus Embolism (VTE): Venous thromboembolism (VTE) is a condition in which a blood clot (thrombus) forms in a vein. Blood flow through the affected vein can be limited by the clot, and may cause swelling and pain. Venous thrombosis occurs most commonly in the deep veins of the leg or pelvis; this is known as a deep vein thrombosis (DVT). An embolism occurs if all or a part of the clot breaks off from the site where it forms and travels through the venous system. If the clot lodges in the lung a potentially serious and sometimes fatal condition, pulmonary embolism (PE) occurs. Venous thrombosis can occur in any part of the venous system. However, DVT and PE are the commonest manifestations of venous thrombosis.

Vital Signs: The assessment, measurement and monitoring of vital signs are important basic skills for all clinical staff. The vital signs we look for include temperature, heart/pulse rate, respiratory rate and effort, blood pressure, pain assessment and level of consciousness. Important information gained by assessing and measuring these vital signs can be indicators of health and ill health.


Part 2

4.0 Kingston Hospital NHS Foundation Trust Priorities for 2016/17

How were the priorities chosen?

Working with stakeholders ensures that the quality priorities selected are pertinent and relevant to service users. In this section we will explain why we think each priority is important, what we aim to achieve, what we have done so far and what we plan to do in the year ahead. Where possible we refer to historical and/or benchmarked data to enable readers to understand progress over time and performance compared to other providers. The number of priorities selected is in line with those stipulated in the Monitor document Detailed Requirements for Quality Reports 2015/16 The description must include:

at least three priorities for improvement (agreed by the NHS foundation trust’s board) indicating the relationship, if any, between the identification of these priorities and the reviews of data relating to quality of care referred to in the assurance statement.

progress made since publication of the 2014/15 quality report – this should include performance in 2015/16 against each priority and, where possible, the performance in previous years

how progress to achieve these priorities will be monitored and measured and

How progress to achieve these priorities will be reported. A long list of potential quality priorities was developed in consultation with stakeholders such

as Healthwatch, Trust committees, commissioners and governors.

The dates of consultation are listed below: Quality Assurance Committee 6th January 2016 Clinical Quality Improvement Committee 7th October 2015 Governors Quality Scrutiny Committee 16th December 2015 Trust Board meeting (public) 27th January 2016 Clinical Quality Review Group 16th March 2016 Kingston Hospital Monthly team brief document 5th February 2016 Healthwatch Forum 10th February 2016 Council of Governors 21 January 2016

The quality priorities long list was then put to a public vote during February 2016. Staff,

volunteers, Trust members and the public were asked to vote on which priorities to select

from the long list. Three priorities were voted for from each domain: patient safety, clinical

effectiveness and patient experience. The priorities with the most votes were selected as the

nine Trust Quality priorities for 2016-17. A total of 304 people completed the quality priorities

survey. The long list (with the eventual priorities that were chosen underlined) is shown

below. Those topics not selected as quality priorities in this Quality Account will be/or already

are incorporated into wider trust quality and safety initiatives.


Domain 1 : Patient Safety – prevent harm

1. Reduce use of agency staff by reducing vacancies. This is important because staff who are permanently employed by the Trust are more likely to be

familiar with our policies, procedures, the Trust values and have access to our programmes of

work to improve patient safety. This was a priority last year.

2. Reduce avoidable harm from sepsis. This is important because sepsis and septic shock have a high mortality and morbidity. If sepsis is

recognised and patients receive antibiotics and fluids early in their treatment the outcome is

improved and this will mean saving lives and reducing harm. It is therefore important that all our

staff and our patients know about the risk of sepsis and that through education and we can

increase awareness of the condition and save lives. This was a priority last year.

3. Reducing falls in the hospital setting. Patients over 65 are vulnerable to falling in Hospital because of their illness, frailty and the

unfamiliarity of the clinical setting. Falls usually delay patient’s recovery and confidence and if

injuries occur, such as hip fractures in the frail patients, the impact of this this can be very

serious. By ensuring that the key recommendations of NICE to prevent falls in adults are

implemented the number of falls should be reduced. This is important because many of the

patient’s at Kingston Hospital are over 65 and we need to ensure that patients don’t have to

spend a long time in hospital and that they are likely to return to their usual place of residence on

leaving.

Improve completion of National Early Warning Score (NEWS) and escalation of the

deteriorating patient. We measure vital signs such as pulse, blood pressure, temperature and

breaths per minute in all of our patients whilst they are in hospital. The most unwell patients have

their vital signs measured more frequently. We do this because these observations tell us

whether patients are responding to their treatment or whether a different treatment is required. All

observations must be completed and the right staff told if there is an abnormality in order that we

give patients the best care.

Reducing Catheter Associated Urinary Tract Infections (CAUTI). CAUTIs are the most

common cause of hospital acquired infections in the UK, accounting for up to 40% of all cases.

Reducing these infections is important as they can lead to lead to pain, discomfort, loss of dignity,

increased length of stay and can lead to sepsis. This priority would therefore focus on reducing

these infections. It is sometimes necessary to catheterise patients for clinical reasons but we

need to ensure that catheters are left in place for the shortest time possible, thus reducing the

potential for infection.

Intrapartum fetal wellbeing assessment and management in high risk pregnancy.This is

important because one of the ways we make sure that babies are safe during labour is to monitor

their heartbeats and the mothers contractions with Cardiotocography (CTG). In order for this to

be used effectively all the midwives and doctors need to be skillful in interpreting what the monitor

is telling us. Misinterpretation of CTGs is one of the commonest mistakes that is seen in claims of

harm to babies. Improving monitoring in labour will enable signs of distress to the baby to be

managed safely and improve the outcome for babies. It also means that caesarean deliveries

might be avoided when the monitoring shows the baby is healthy.

Reduce the risk of Hospital Acquired Thrombosis (HAT). This is a condition where patients


can get blood clots in the veins of their legs which causes swelling and pain but can also lead to a

blood clot travelling to the lungs, which is dangerous. In hospital we assess everybody for their

risk of getting this condition but some patients are particularly at risk and may need extra

intervention. We need to reduce the risk of HAT by making sure that we analyse every time this

happens so we can learn how to prevent the condition in more of our patients.

Domain 2 - Clinical Effectiveness - improve clinical outcomes for our patients

4. Reduction in patient reported pain. This is important because it is an area where we can make improvement. We know this because

our inpatient survey told us that we do not always recognise and treat pain effectively. We also

know that patients with dementia are particularly vulnerable to not receiving enough pain relief.

We will make it a priority to ensure all our staff know how to assess that pain is being managed

effectively even when it is difficult for our patients to explain this to us. We will also ensure that

we use the most effective interventions to manage pain well.

5. Reduction in readmissions in non-elective care. We want to ensure that people don’t have to stay in hospital any longer than is needed. But we

must not send patients home too soon or without the right treatments to continue, or the right

instructions about how to manage when they leave. We will make reducing the frequency that

readmissions occur a priority, by making sure that we make the right plans with our patients so

that they do not have to come back to the hospital.

6. Reduction in length of stay. This is important because staying in hospital for longer than necessary can be harmful as well as

inconvenient. This is especially true for frail and elderly patients who can become very weak in

hospital and are at greater risk of falling or getting pressure sores and infections. We will work to

make sure that we reduce any delays in hospital waiting for investigations and test results and

that when it comes to the time to go home we have planned what is required and made sure that

everything is ready at discharge.

Increase 7 day working provision. Emergency services are available every day in the hospital

but they are not always the same as during the week. We will work to provide services that are

important at weekends as well as week days if this means that our patients don’t have to wait as

long for their treatment and we will increase the number of senior doctors who are available to

look after our patients, especially on our Acute Assessment Ward. This was a priority last year.

To work towards ‘paperlight’ using information technology and record management in

Outpatients. This is important because; implementing electronic patient records and information

technology solutions help reduce the amount of time staff spend on administrative tasks. This

releases more time for them to provide patient care. It also allows us to introduce systems that

support improved patient safety.

Hospital mortality index better than expected. This is a measure that compares results

between hospitals. Kingston Hospital has a lower mortality index than many hospitals. We will

look at our results in detail and the areas where we can make improvements we will take action to

ensure that all areas of the hospital have a low mortality.

Domain 3 - Patient Experience - listen and respond to patients’ concerns


7. To transform administration across the hospital. One of the areas that patients and GP’s have told us we need to improve on is our administration.

This includes such things as how clear patient letters are, and the ease of making and changing

appointments. This priority would therefore seek to improve the experience of the Trusts

administration processes. This was a priority last year.

8. Improve end of life care. There is only one opportunity to get the care at the end of a patient’s life right for both them and

their loved ones. This priority would therefore focus on making improvements in the care given to

patients at the end of their life and the experience of their loved ones at this difficult time. This

was a priority last year.

9. Improve experience of discharge. Ensuring patients are discharged in a planned and timely way, with good communication with

external parties is a critical to ongoing patient care. This priority would seek to increase

understanding of patients experience of the discharge process and make improvements to that

experience. This was a priority last year.

Improving the experience of patients with dementia in outpatient settings. As part of the

Trusts Dementia Strategy we have significantly focused on improving the care of patients and

their carers within inpatient settings. We will continue to do this, but we know that of the 350,000

patients that attend our outpatient settings each year also have a significant proportion that are

affected by dementia. This priority would therefore focus on ensuring patients with dementia and

their carers receive a positive experience of our services, and specific actions are in place to

address their needs in these settings. This was a priority last year.

Improving the experience of children & young people. The majority of children and young

people are seen and treated in specific children & young people’s settings. Due to the specific

nature of some outpatient and emergency services some children & young people have to be

cared for within areas which predominately treat adult patients. For example places such as the

Royal Eye Unit, A&E, our x-ray and CT departments, or our dental services. It is important that

any child or young person coming to hospital receives the best experience wherever they are

seen, and this priority would focus on ensuring this is the case.

Improve the experience of seldom heard groups and/or those with protected

characteristics. There are groups in the communities that we serve that are seldom heard or

who have additional needs that require specific attention so that our services are equally

accessible, they are not disadvantaged or have a poor experience of our services. Examples of

this include people with vision or hearing impairment, are lesbian, gay, bisexual or transgender or

those from black, Asian or minority ethnic groups. This priority would therefore focus on

identifying specific seldom heard and/or groups with protected characteristics that we could work

with to ensure a positive experience of our services. If you have specific suggestions of seldom

heard groups or those with protected characteristics that you believe warrant the specific attention

of the Trust please can you provide below.


Quality priorities for 2016/17 The quality priorities for the forthcoming year are shown below. As well as new priorities we are also continuing to build on achievements in ongoing priorities in sepsis, administration, End of Life Care, reducing vacancies and discharge.

Domain

Priority

Patient Safety

1) Reduce falls in the hospital setting 2) Reduce avoidable harm from sepsis 3) Reduce use of agency staff by reducing vacancies


1) Reduce readmissions in non-elective care 2) Reduce length of stay 3) Reduce patient reported pain

Patient Experience

1) Transform administration across the hospital 2) Improve end of life care 3) Improve patient experience of discharge

Domain: Patient Safety

Priority 1 - Reduce falls in the hospital setting

Goal Aim Actual Performance (2015/16)

KHT Data Available

Benchmarked/ Comparison

Safety Prevent inpatient falls: Meet all 7 key recommendations regarding care to avoid falls Achieving no red ratings in the National Inpatient Falls Audit and increase 2015 amber scores to green

National inpatient fall audit results 2015 for Kingston Hospital Red: Scored 0-49% in the following

Dementia and Delirium

Blood pressure

Medication Review

Walking aids

Continence Care plan

Amber Scored 50% - 79% in the following

Call Bells

Visual impairment

Yes National inpatient falls audit results

Measure:


Increase in the proportion of patients who received assessment/intervention for the 7 key recommendations regarding care to avoid falls.

Continued monitoring for improvement in the overall inpatient falls rate. Reference for data source: National inpatient fall audit results

Governed by standard national definitions? NICE guidance and national inpatient falls audit measures

Why we chose this indicator?

Patients over 65 are vulnerable to falling in hospital because of their illness, frailty and the unfamiliarity of the clinical setting. Falls usually delay patient’s recovery and confidence and if injuries occur, such as hip fractures in frail patients. The impact of this this can be very serious. By ensuring that the key recommendations of NICE to prevent falls in adults are implemented the number of falls should be reduced. This is important because many of the patient’s at Kingston Hospital are over 65 and we need to ensure that patients don’t have to spend a long time in hospital and that they are likely to return to their usual place of residence on leaving. NICE guidance on falls prevention has strongly advised that we should not undertake falls assessment but instead identify all patients over 65 to be at risk. This was supported by the findings from the National Audit of Inpatient Falls report 2015 which strongly recommended for Trusts to stop using a fall risk prediction tool and instead put forward 7 ‘key indicator’ recommendations for a multifactorial falls assessment:

1. Dementia and delirium – We recommend that all trusts and health boards review

their dementia and delirium policies to embed the use of standardised tools and

documented relevant care plans. Falls teams should work closely with dementia and

delirium teams (if present) to ensure team working for these high-risk patients.

2. Blood pressure – We recommend that all patients aged over 65 years have a lying

and standing blood pressure performed as soon as practicable, and that actions are

taken if there is a substantial drop in blood pressure on standing.

3. Medication review – We recommend that all patients aged over 65 years have a

medication review, looking particularly for medications that are likely to increase risks

of falling.

4. Visual impairment – We recommend that all patients aged over 65 years are

assessed for visual impairment and, if present, that their care plan takes this into

account.

5. Walking aids – We recommend that trusts and health boards develop a workable

policy to ensure that all patients who need walking aids have access to the most

appropriate walking aid from the time of admission. Regular audits should be

undertaken to assess whether the policy is working and whether mobility aids are

within the patient’s reach, if they are needed.

6. Continence care plan – We recommend that all patients aged over 65 years have a

continence care plan developed if there are continence issues, and that the care plan

takes into account and mitigates against the risks of falling.


7. Call bells – We recommend that all trusts and health boards regularly audit whether

the call bell is within reach of the patient and embed the change in practice if needed.

How will progress be measured? Clinical audit and review

How will progress be monitored? Achievement of the project milestones

Lead Committee Falls Group

Lead Executive Medical Director

Priority 2 – Reduce avoidable harm from sepsis


KHT Data Available


Safety Eliminate all avoidable deaths from sepsis and septic shock, by implementing year 2 of the Sepsis Sign up to Safety plan

Measure lactate levels: 60% Obtain blood cultures prior to administration of IV antibiotics: 68.8% Administer broad spectrum antibiotics: 85.7% (Dec 15) Administer 30ml/kg Crystalloid for hypotension or lactate >4mmol: 33.3%

Yes No

Measure:

Improving the recognition and treatment of severe sepsis and septic shock through education and increased awareness. The targets for year 2 are shown below

Sepsis Sign up to Safety Plan targets

Sepsis Six goals within 3 hours Year 2 16/17 target

Measure lactate levels 70%

Obtain blood cultures 60%

Administer broad spectrum antibiotics 90%

Commence IV fluids 70%


Medical staff conducting review of patient records (mortality and morbidity review) identifying avoidable and unavoidable deaths

Reference for data source: Clinical Coding data and clinical audit

Governed by standard national definitions? Yes, Sepsis 6 bundle definitions


Sepsis was a quality priority last year and we made a number of successful improvements. We are now focussing on achieving year 2 of the Sepsis Sign up to Safety plan. Sepsis and septic shock have a high mortality and morbidity. If sepsis is recognised and patients receive antibiotics and fluids early in their treatment the outcome is improved and this will mean saving lives and reducing harm. It is therefore important that all our staff and our patients know about the risk of sepsis. Through education we can increase awareness of the condition and save lives. We have already made improvements and more are planned in the next year.

How will progress be measured? Via Clinical audit and review

How will progress be monitored? Achievement of the project milestones

Lead Committee Clinical Quality Improvement Committee

Lead Executive Medical Director



KHT Data Available


Safety Develop and implement

targeted recruitment and

retention strategies to

recruit and retain

permanent staff; and reduce

the use of agency workers

Reduction in vacancy rates from 14% to 6.28 % between April 2015 and March 2016

Yes

No

Measure:

Substantive establishment recruited and maintained at 95% supported by 5%

temporary staffing.

Overall reduction in vacancy rates from 7% to 5% and a reduction in turnover.

(Targets for each staff group currently under review)

Reference for data source: Financial data and electronic staff roster system

Governed by standard national definitions? No



This is important because staff who are permanently employed by the Trust are more likely to be familiar with our policies, procedures, the Trust values and have access to our programmes of work to improve patient safety. Staff retention is an essential part of developing staff roles and teams and providing consistent care to patients. High levels of vacancies and extensive use of agency staff can have a detrimental effect on patient satisfaction and staff morale. Increasing the number of substantively employed staff will be beneficial in terms of quality, stability and continuity. As part of the Lord Carter review of efficient use of resources in the NHS, reducing agency costs is important to avoid expenditure which could be reinvested in patient care.

How will progress be measured? Quarterly review of performance

How will progress be monitored? Monthly budget statements/ Electronic staff roster system

Lead Committee Workforce Committee

Lead Executive Director of Workforce

Domain: Clinical Effectiveness

Priority 4 – Reduce re-admissions in non-elective care



KHT Data Available

Effectiveness Reduce non-elective readmissions following either elective or non-elective care A&E and Acute Assessment Unit (AAU), Respiratory, Trauma & Orthopaedics

Kingston average % A&E and AAU 17.8 Trauma and Orthopaedics 4.9 Respiratory 14.5

Peer average %: A&E and AAU 14.3 Trauma and Orthopaedics 4.3 Respiratory 13.2

Yes (Updated using CHKS, covers period Apr-15 – Jan-16)

Measure:

Reduction in non-elective readmissions following either elective or non-elective care by March 2017 on A&E and AAU, Trauma and Orthopaedics and Respiratory wards (achieve national average).


Reference for data source: Service Line dashboards and CHKS information system

Governed by standard national definitions? Hospital Episode Statistics definitions

We want to ensure that people don’t have to stay in hospital any longer than is needed. But we must not send patients home too soon or without the right treatments to continue, or the right instructions about how to manage when they leave. We will make reducing the frequency that readmissions occur a priority, by making sure that we make the right plans with our patients so that they do not have to come back to the hospital. We have chosen these departments as they are the areas when compared to the national average that offer the most opportunity for improvement.

How will progress be measured? Monthly data collection

Audit of discharge plans

How will progress be monitored? Monthly Hospital performance reports and Service Line dashboards

Lead Committee Executive Management Committee

Lead Executive Chief Operating Officer

Priority 5 – Reduce length of stay



KHT Data Available

Effectiveness Aim to reduce the length of stay for patients on elderly care, Respiratory and cardiology wards

Kingston average: Elderly Care 18.1 days Respiratory 9.3 days Cardiology 5.0 days

Peer average: Elderly Care 11.2 days Respiratory 5.8 days Cardiology 3.0 days

Yes (Updated using CHKS, covers period Apr-15 – Jan-16)

Measure:

Reduction in length of stay for non-elective care by March 2017 on Elderly Care, Respiratory wards and Cardiology wards (achieve national average).

Reference for data source: Service Line dashboards CHKS information system

Governed by standard national definitions? Yes Hospital Episode Statistics definitions


Staying in hospital for longer than necessary can be harmful and disruptive for patients. This is especially true for frail and elderly patients who can become very weak in hospital and are at greater risk of falling or getting pressure sores and infections. We will work to make sure that we reduce any delays in hospital waiting for investigations and test results and that


when it comes to the time to go home we have planned what is required and made sure that everything is ready at discharge. We have chosen these departments as they are the areas when compared to the national average, offer the most opportunity for improvement.

How will progress be measured? Monthly data collection

How will progress be monitored? Monthly Hospital performance reports

Clinical audit of discharge plans

Lead Committee Executive Management Committee


Priority 6 – Reduce patient reported pain

Goal Aim Actual Performance

(2015/16) KHT Data Available


Effectiveness To increase patient satisfaction with pain management

Baseline to be established based on previous national survey results -Children and young people Survey 2014: for parents and carers saying they thought staff did all they could to ease their child's pain Score: 8.4/10 -National Inpatient survey 2014: Hospital staff did all they could to help control their pain, if they were ever in pain Score 8.1/10 -Accident and Emergency Survey: 2014: Hospital staff did all they could to help control their pain, if they were ever in pain while in A&E 7.2/10 -Not having a long wait to receive pain relief if requested Score: 5.8/10

No Yes (Awaiting 2015 results)

Measure:

Patient satisfaction with pain management during inpatient or emergency care (baseline to be established)

Pain medication clinical audit results (baseline to be established)

Reference for data source: Patient survey, complaints and clinical audit




This is an area where we can make improvement. We know this because our inpatient and other surveys told us that we do not always recognise and treat pain effectively. This issue has also been raised in complaints. We also know that patients with dementia are particularly vulnerable to not receiving enough pain relief. We will make it a priority to ensure all our staff know how to assess that pain is being managed effectively even when it is difficult for our patients to explain this to us. We will also ensure that we use the most effective interventions to manage pain well.

How will progress be measured? Patient survey

Clinical audit of pain medication

Complaints

How will progress be monitored? Regular reports to the Pain Management Group

Lead Committee Pain Management Group

Lead Executive Director of Nursing & Patient Experience

Domain: Patient Experience

Priority 7 – Transform administration across the hospital


KHT Data Available


Experience Transform patient

administration and the

delivery of outpatient

services

Admin related

complaints 2015-16

=143

Yes No

Measure:

50% reduction in the number of complaints regarding patient administration

Reference for data source: Complaints received, Clinic reports




One of the areas that patients and GP’s have told us we need to improve on is our administration. This includes such things as how clear patient letters are, and the ease of making and changing appointments. This priority would therefore seek to improve the experience of the Trusts administration processes. An analysis of our complaints shows that making and changing appointments is an area we need to improve. Improvements have been made during 2015 and it is important that these changes are sustained which is why we are aiming to halve complaints by making the appointment process clearer and easier.

How will progress be measured?

Monitor complaints via service and type to assess where improvements are being made.

How will progress be monitored? Monthly reports

Lead Committee: Patient Experience Committee

Lead Executive: Chief Operating Officer

Priority 8 – Improve end of life care


KHT Data Available


Experience To improve the experience of patients and their relatives of end of life care

KHFT Bereavement survey which was benchmarked against National Audit Survey Results* -Time to listen and discuss condition Doctor Score: 79% (national score was 74%) Nurse Score: 77% (national score was 74%) -During the last 2 days involved in decisions about care and treatment. ‘Not involved’ score: 16% (national score was 24%) -Explanation of condition: ‘Did not explain’ score was: 5% (national score was 12%) -Spiritual needs were met by the healthcare team ‘Strongly agree’ score was : 12% (national score was 13% ‘Agree’ score was 30% (national score was 22%)

Yes Yes Care of the Dying Evaluation. National Audit Survey

*Trust used a standard validated self-completion questionnaire developed by Marie Curie: the Care of Dying Evaluation (CODE) survey. Data derived from the annual National


Bereavement Survey ‘VOICES’ 2013 in which Kingston data is included within overall results, has been used as a indicative benchmark. Measure:

Care of the dying survey results

Improved staff confidence in communicating with patients and carers before, during and following the dying phase

Improved use of spiritual support services.

Reference for data source: Bereavement survey



End of Life Care was a quality priority last year and we made a number of successful improvements. There is only one opportunity to get the care at the end of a patient’s life right for both them and their loved ones therefore it is important that this is an ongoing prirotiy. This priority will therefore focus on making improvements in the care given to patients at the end of their life and the experience of their loved ones at this difficult time as well as supporting staff to provide the right care to patients and communicating effectively with carers.

How will progress be measured? Annual audit of bereavement survey

How will progress be monitored? End of Life Care Steering Group

Lead Committee Patient Experience Committee

Lead Executive Director of Nursing and Patient Experience

Priority 9 – Improve patient experience of discharge

Goal

Aim

Actual Performance (2015/16)

KHT Data Available


Experience To ensure that the patient’s discharge is timely, efficient and that patient experience is optimised

Delayed Transfer of Care (DTOC) performance was approximately 5.8%

baseline to be developed

Local DTOC target of 4% and national target 2.5%

Measure:

Reduction in the number of delayed transfers of care and the number of internally reported delays to at least the local target of 4%.

Reference for data source:


Patient tracking list, feeding into daily DTOC and monthly submission.

Business intelligence reports on time of discharge home.

Governed by standard national definitions? Yes, the London Quality Standards


Local and National Healthwatch feedback has highlighted the importance of good discharge practices and the negative impact a poor discharge experience can have on patients and carers.

Discharge planning for many patients is complex and requires not only the timely implementation of medical and nursing care but also collaboration with other internal and external departments. E.g. social care, community nursing services. Transferring home following a period in hospital can cause concern to the patient. It is therefore critical that discharge planning is timely, that communication with patients, families and professionals is effective and that all services are in place before the patient leaves the hospital.

Effective discharge planning ensures that patients are discharged early in the day and that the hospital bed is then made available for another patient, improving patient flow from ED to AAU and from AAU to the Ward. This in turn improves the inpatient experience for the newly admitted patients.

How will progress be measured?

DTOC performance will be measured against the local target of 4%

Patients discharged before lunchtime will be measured

Friends and Family response from the discharge lounge

How will progress be monitored? Monthly DTOC submission

Monthly report on the timing of discharge

Monthly FFT report.

Lead Committee Patient Experience Committee



Part 3

5.0 Looking Back at 2015 /16 In December 2014 and January 2015 an online survey was conducted to identify the preferred quality priorities of Kingston Hospital NHS Foundation Trust Members and staff and other stakeholders with almost 140 responses received. These were combined with feedback from various committees and forums to determine the Trust’s priorities. The following table outlines the chosen priorities. We deliberately set challenging targets to further quality improvements for patients.

Last year’s priorities: Domain

Priority

Patient Safety

- Improved recognition and management of

sepsis in hospital

Partly

Achieved

- Implement patient safety elements of Year 2

of the Dementia Strategy

Partly

Achieved

- Reduce use of agency staff by reducing

vacancies

Partly

Achieved


- Work towards paper-light systems using

information technology and record

management across the Trust

Achieved

- Ensure all our staff are up to date with core

(mandatory) training, have clear objectives,

regular appraisal and a personal

development plan reflecting our values

Achieved

- Increased provision of 7 day working of key

staff and services Achieved

Patient Experience

- Transform administration across the hospital

and make improvements in administration

Partly

Achieved

- Improve patients’ and their relatives’

experience of End of Life Care

Achieved

- Improved discharge planning and processes Achieved

The Quality Report is now established as an important means of demonstrating and communicating improvements in the quality of patient care. We will continue to focus attention on making our Quality Report more readable and accepted as a core instrument in improving accountability to the public.


Domain: Patient Safety

Priority 1 - Improved recognition and management

of sepsis

Goal

Aim

Safety

Eliminate all avoidable deaths from sepsis and septic shock

Measure:

We plan to achieve the targets set out within the Sepsis 6 treatment bundle for 90% of our patients by December 2018 (we will set a trajectory for achievement in 2015 to deliver this year and each year to 2018).

We will do this by improving the recognition and treatment of severe sepsis and septic shock through education and increased awareness.

Medical staff conducting review of patient records (mortality and morbidity review) Reference for data source: Clinical Coding data and Clinical Audit Governed by standard national definitions? Sepsis 6 bundle definitions

Why did we choose this?

This indicator was chosen because sepsis and septic shock are treatable conditions that have a high mortality if not recognised promptly. Improving the recognition and treatment of severe sepsis and septic shock through education and increased awareness will therefore save lives. The UK Sepsis Trust estimates that there are approximately 150,000 hospital admissions for sepsis each year with an average cost of £20,000 for each patient looked after. What we said we were going to do?

We planned to achieve Sepsis 6 treatment bundle targets for 90% of patients by December 2018. We set a trajectory to achieve delivery in 2015 and each year to 2018. We planned to improve the recognition and treatment of severe sepsis and septic shock by providing education sessions across the Trust to ensure that staff are aware of the signs of sepsis, monitoring uptake by staff group. A coding mechanism would be introduced to facilitate identification and tracking of patients diagnosed with severe sepsis or septic shock in order to monitor compliance with timelines and recommendations for treatment set out in the Sepsis 6 recommendations.

How did we do?

Partly Achieved


The 3 target trajectory for our Sepsis Improvement plan is shown below

Sepsis 6 treatment bundle

Sepsis Six goals within 3 hours Target Year 1 target 1516

Year 1 achievement

Measure lactate levels 95% 85% 60%

Obtain blood cultures prior to

administration of IV antibiotics 70% 50% 68.8%

Administer broad spectrum

antibiotics 95% 85% 85.7%

Administer 30ml/kg Crystalloid for

hypotension or lactate >4mmol 90% 70% 33.3%

In January 2015 we set the above trajectory as part of Sign up to Safety plan. In April 2015 a national CQUIN was introduced for sepsis which concentrated on sepsis screening and the prescribing of antibiotics. The table below shows progress with further actions to improve recognition and treatment of

sepsis

Action Progress

Educating staff GP training session held

Staff reminded of the Mortality and Morbidity process

Training and education programme includes:

-Ward based training: Nurses/HCAs – 350 staff trained by Sepsis

Nurse Specialist/Outreach Team

-Sepsis simulation training – approx 120 staff trained

-Training for each F1, F2, CT doctor intake

-Sepsis training at nurse/HCA induction

-Internal webpage hosts educational material

-Posters in departments

-Aide-memoire cards for clinicians

Coding of sepsis Coding mechanism in place

Other actions:

Intranet information site for staff launched

External webpage for public being developed


Case note review of sepsis deaths

Clinical guideline produced

Competency framework developed with training for nurses to take

blood cultures in the A&E Department

Trialling of sepsis alert for electronic patient record

Trial of designated sepsis nurse, sepsis bag/trolley in the A&E

Department

Picture shows Staff in Sepsis simulation training scenario


Priority 2 - Implement patient safety elements of Year 2 of the Dementia Strategy

Goal

Aim

Safety Implementation of the patient safety element of year 2 of the Trusts Dementia

Strategy: identify and monitor scale of harms (e.g. falls, pressure ulcers, etc) for

patients with dementia and set year on year reduction targets for this group

Measure:

We will set up systems that are able to specifically identify the level of harm to patients with

dementia. We will establish a baseline of incidents and we will reduce the rate of harms to

these patients by 10% in Q4 compared to the baseline in Q1. Having identified the key harm

levels (e.g. falls, pressure ulcers in patients with dementia) we will plan a targeted safety

improvement programme by September 2015.

Reference for data source: Incident Reporting Governed by standard national definitions? No Why did we choose this? Improving care for patients with dementia is an important issue for Kingston Hospital reflected in the Trust’s Dementia Strategy 2014-2017. The life expectancy in our local population is high; as a result, nearly twice as many of our patients have Dementia compared to the national average. Patients with dementia are at an increased risk of harm whilst in hospital, such as falls, pressure ulcers and hospital-acquired infections. What we said we were going to do? In year 2 (2015/16) of the Dementia Strategy we planned to set up a system to identify incidents resulting in harm to patients with dementia. A baseline of such incidents was to be established in Q1 with the aim of reducing the rate of harm by 10% in Q 4. The Dementia Strategy Group will utilise these reports along with other measures such as the carers’ FFT put in place in 2014/15 to track progress and develop further interventions to drive improvement. A targeted safety improvement programme was planned to be in place by September 2015.

How did we do?

We have put in place systems that enable us to easily identify through incident reports

patients with dementia. A dementia score card is being developed to track specific harms

alongside other information about patients with dementia including length of stay, late

Partly Achieved


transfers, re-admissions and discharge destinations. The dementia strategy group will utilise

these reports alongside other measures such as the carers FFT we put in place in 2014/15,

to track progress and develop further interventions to drive.

The incident data that has been collected so far has been analysed to look at which specific

harms related to dementia require monitoring. The specific harm identified is predominantly

patient falls. From mid-August to November 2015, 47% of incidents featuring dementia were

accidents, of which 86 % were patient falls.

This work has already led to a number of improvements. Improvements are being made to

toilet signage by painting the doors yellow and replacing signage with large pictorial signs

will help patients find the toilet, which can often be a related to patient falls. The proposed

improvements to Derwent ward including changes to flooring and lighting will impact on falls

rates and falls with harm.

Dementia awareness training taking part across the trust will increase knowledge and

awareness of how to assist patients with dementia that may in turn reduce falls with harm.

In addition the following has been achieved as part of year two or the dementia strategy

Dementia service lead in post –as of Dec 2015

Increased training provision of dementia awareness sessions

Analogue clocks put up throughout wards with date and day

Activities programme further established with full timetable running 5 days a week

Signed up to John’s campaign

carer feedback sessions

We have only partly met this priority because we did not implement the monitoring until mid-August and therefore could not demonstrate an improvement by Quarter 4. However, now that harms for dementia patients are being recorded and better understood it will be possible to track and reduce these harms, for example by reducing falls. The Trust will continue to build on this work as part of the Dementia strategy year 3.



Goal

Aim

Agency Expenditure (KHFT data used) (2015/16)

Safety To reduce agency usage by 10%

£18,009,200 (all staff groups) (15-16)

£12,354,000 (14-15)

Reduction in vacancy rates from 14% to 6.28 % between April 2015 and March 2016

Measure:

To increase recruitment to substantive posts and reduce the requirement to engage agency staff by 10%.

Reference for data source: Financial data and electronic staff roster system



Kingston Hospital has to be able to respond to fluctuations in service demand by means of flexible staffing arrangements. The use of agency staff forms a key part of this flexibility; however, reliance on usage of agency staff can be costly. High levels of vacancies and extensive use of agency staff can have a detrimental effect on patient satisfaction and staff morale. Increasing the number of substantively employed staff will be beneficial in terms of quality, stability and continuity. Our own staff are more likely to be familiar with our policies, procedures, Trust values and have access to our programmes of work to improve patient safety.

What we said we were going to do?

We said we would increase recruitment to substantive posts and reduce the requirement to engage agency staff by 10%.

How did we do?

There has been an active recruitment process, including recruiting cohorts of band 5 nurse

and nursing assistants, as well as seeking additional staff from overseas to fill vacant posts.

Investments made over the year had a positive impact on recruitment and retention with a significant reduction in vacancy rates from 14% to 6.28% between April 2015 and March 2016 and a small reduction in turnover. Investments included international recruitment campaigns, more practice development nurses to support new recruits, the Kingston Positivity Programme and training on a coaching approach to 1:1s and appraisals.

Partly Achieved


There is now an improved induction programme, including a buddy system, and feedback is

sought from new starters to further improve service. In addition to filling vacant posts, there

has been work to increase retention of existing staff by improving training, development and

career opportunities, plus staff satisfaction and motivation. A positivity programme was

launched and attended by 150 staff, and the inaugural #TeamKHFT Annual Awards were

held.

Agency use is still a challenge, safe staffing numbers need to be maintained on the wards.

Although we have not made the progress we had hoped in reducing temporary staffing

usage, primarily reflecting substantive recruitment challenges and agency pricing issues

effecting the NHS more widely, we have managed to reduce the amount we spent on

agency staffing during the year. For the first half of the year we spent, on average, £1.6m

per month on agency staffing. This average reduced to £1.4m per month for the second half

of the year, a reduction of approximately 7%. The Trust is committed to reducing agency use

and this will be a priority again for 2016/17.

The following activities have been undertaken to support recruitment:

Linking with local partners

Wholesale redesign of the in-house recruitment process in 2015/16. This has improved

efficiency and improved lead times to recruit

Ongoing investment in international recruitment which yielded significant numbers of new

nurses in 2015/16

A recently developed predictor tool which enables service lines and corporate

departments to forward-plan recruitment, dovetailing with a range of incentives and

bespoke approaches to help with recruitment of hard-to-fill post. Established vacancy

control panel to ensure a reduction in agency spend and temporary staffing usage

overall.

Further investment is planned for e-roster roll out to ensure all staff are on the system

and are rostered.


Domain: Clinical Effectiveness

Priority 4 - Work towards paper-light systems using information

technology and record management across the Trust

Goal

Aim

Effectiveness

Increase the amount of time nurses have available to spend with patients by introducing electronic recording of vital signs

Measure:

The initial scope of this project will be focusing on releasing nursing time to care and

reduce the amount of time nurses take to obtain and record patient’s vital signs.

We will establish a baseline prior to implementation of the project and improvement

trajectory based on this baseline. (100 beds in first phase)

To reduce human error in recording patient’s vital signs

To reduce the time taken to respond to the patients deteriorating condition

Reference for data source: Audit of patient safety alerts, system reports



The implementation of electronic patient records and information technology solutions help reduce the amount of time staff spend on documentation. This releases more time for them to provide patient care. It also allows us to introduce systems that support improved patient safety. This application enables nurses to electronically record patient’s vital signs observations at the bedside in real time. An alert mechanism enables medical and critical care teams to respond to deteriorating patients allowing for swift intervention and treatment.

Where nurses have access to information at the bedside, they can make quicker decisions. Where they’re free from administrative burdens, they have more time for patient care. Where automated alerts prevent medication errors, patients are safer. Information underpins improved care.


The initial scope of this project will focus on releasing nursing time to care and reducing the amount of time nurses take to obtain and record patient’s vital signs. The system will cover 100 beds at the Trust initially, based on the funding secured via a national bidding process to support nurses’ use of information technology to improve patient care.

Achieved


We will establish a baseline prior to implementation of the project and set an improvement trajectory which will enable us to demonstrate reduced human error in recording vital signs and reduced time taken to respond to a deteriorating patient’s condition.

How did we do?

During 2015 Kingston Hospital introduced new equipment the wards that enable patients’

vital signs such as blood pressure and temperature to be recorded electronically. This is to

help further improve patient care and free up nursing time so they have more time to spend

with patients’.

The new Vitals Devices (Welch Allyn’s) allow staff to send data when taking observations

straight into an electronic patient record system called Care Records Service (CRS), the

Trust’s electronic patient system. This has allowed key nursing time to perform other tasks

and improve the speed at which data is available to the clinical teams to review.

Staff can make faster decisions as they are alerted to abnormal and accurate readings

immediately. The margin for error is greatly reduced by removing the need to transcribe

information. The response from staff has been very positive.

As part of the roll out of the system the time saved has been monitored, and an average of

1.5 minutes of nursing time is saved for each set of observations taken on a patient. Based

on the number of observations taken in one month (n=9,000) across these three wards, 225

hours of nursing time has been released in one month from this systems implementation.

With the deployment of the clinical record system (CRS) nursing documentation, has allowed

focus on alternative methods of auditing the information directly from the system. The

purpose of this is to release time from nurses collecting and inputting audit data. Since

October 2015 the monthly documentation audit is now undertaken directly from the system.

We plan to extend this system into A&E during 16/17, and other areas as funding allows.


Priority 5 - Ensure all staff are up to date with core (mandatory) training, have clear objectives, regular appraisal and a personal development plan reflecting our values

Goal

Aim

Actual Performance (KHFT data used) (2015/16)

Effectiveness To have a committed, skilled and highly engaged workforce who feel valued, supported and developed working together to care for our patients

88% Appraisal completed 86% Mandatory training (as of w/c 23.02.16)

Measure:

80% of staff to have had an appraisal and agreed objectives and a personal development plan (PDP) by the end of September 2015 and 95% by March 2016.

All managers have feedback on their people management skills from their staff and have the results built into their PDP.

80% of staff up to date with their mandatory training by end of March 2016

10% improvement in the reports from staff who say their appraisal left them feeling valued.

Reference for data source: Electronic Staff Record (OLM system)

Annual Staff Survey results

Governed by standard national definitions? Yes


The annual Staff Survey in 2014 demonstrated a reduction in employee engagement compared with previous years. Information from exit interviews, 100 day new starter surveys and the views expressed in “conversations with the Board” identified that development and recognition are important issues for staff.

Staff who are regularly trained and updated in core subjects (Mandatory Training) are better equipped to deliver safe care.

Giving feedback regarding performance, setting objectives, and creating personal development plans all lead to better staff engagement. Regular appraisals and one to one discussions with managers can improve staff commitment. This is a crucial part of our campaign to ‘make a difference’ and encourage positivity in staff.


80% of staff to have had an appraisal, agreed objectives and a personal development plan (PDP) by the end of September 2015 and 95% by the end of March 2016.

Achieved


All managers to have feedback on their people management skills from their staff and have the results built into their PDP.

80% of staff will be up to date with their mandatory training by end of March 2015

10% improvement in the reports from staff who say their appraisal left them feeling valued.

How did we do?

We have achieved 86% total trust compliance for Statutory & Mandatory training by the

following:-

Compliance reporting available for all to view via the intranet. Individuals and

managers are able to view compliance for all Statutory & Mandatory subjects.

Dates available for the whole of 2016 for face to face classroom sessions of

Pt manual Handling, Resuscitation, Fire and Conflict resolution.

Specific 3 in1 sessions available for Manual Handling, Basic Life Support and

Fire to allow staff to be released in one go

Consultant specific session dates available throughout the year to allow for

planning and reduction in clinic cancellations

Training delivered within departments particularly specialised areas and

training on governance protected time.

Education Centre and HR Business Partners are working with service lines to

monitor compliance and actions around low compliance

Flexibility with training sessions and trial of different times/days

Mandatory training materials have been reviewed so that it is now delivered via various media (online, face-to-face and booklets) to improve accessibility and target resources to staff groups. Face-to-face training is delivered flexibly to enable front-line staff to attend whilst maintaining continuity of patient services.

We have achieved 88% for appraisals completed which is above target. We have been encouraging staff and managers to see the benefits of receiving feedback and having clear objectives as part of the appraisal process.

There are some very encouraging scores in our 2015 Staff Survey results showing an

increase in the number of staff feeling that their immediate manager values their work and

staff agreeing that their manager gives clear feedback on work. We attribute this to the

following:

All existing and new managers are encouraged to attend the Coaching Approach for

one to ones and appraisals workshop; nearly 400 managers have already attended

this workshop.

There has also been active involvement by the HR Business Partners to ensure that

each Service Line achieves their key performance indicators.

Unfortunately we could not measure any improvements in staff who say their appraisal left

them feeling valued, as this question was changed in the staff survey. Therefore there are no

comparable results available for this year in the national survey to this specific question. We

have as a corporate objective to improve the day to day experience of staff at Kingston

during 16/17.


Priority 6 - Increase provision of 7 day working of key staff and

services

Goal

Aim

Effectiveness To improve the provision of 7 day working in the Trust and improve achievement of the London Quality Standards (related to consultant presence in Paediatrics, Surgery and Medicine) To have consultant ward reviews, every day, on every ward (including the acute assessment unit)

Measure:

Analysis of medical staff job plans to ensure daily ward reviews are included in the work profile for staff

Length of stay on inpatient wards (including comparisons for week day and weekend admission dates to ensure reduced variation)

Reference for data source: Clinical Audit and Effectiveness audit. Job plan review.

Governed by standard national definitions? Yes, London Quality Standards

Benchmark: London Quality Standards audit results


The Trust is making a significant investment in seven day working to ensure patients get the same level of care irrespective of the day of the week. To date, mortality of patients admitted at the weekend has been higher than that of patients admitted on a weekday. We also know that reviews of patients by senior doctors with the support other healthcare professionals and access to diagnostic tests would make the patient’s stay more efficient and would probably reduce the time that a patient spends in hospital.

Fewer patients are discharged at the weekend making the hospital very busy at the beginning of each week with few empty beds; this slows down transfers out of the Emergency Department and makes the four hour standard very difficult to achieve.


This investment will enable consultant ward reviews seven days a week for all patients in the hospital by the end of the year. We will have increased numbers of therapists and pharmacists working in the hospital at the weekend as well as other support staff who are vital to achieving the right standards of care every day. Analysis of medical staff job plans will be undertaken to ensure daily ward reviews are included in the work profile for staff. Length of stay on inpatient wards will be monitored (including comparison of weekday and weekend admission/discharge rates).

Achieved


How did we do?

During 2015/16 the Trust made some essential investments in quality which, alongside a

review of staffing structures and adjustments to job plans, supported progress against

achievement of the London Quality Standards including the delivery of 7-day services. The

full year effect of a number of these initiatives will be realised in 2016/17. Initiatives include:

Recruitment of 3 Emergency Surgeons to deliver improved emergency services,

ensuring quality standards are delivered;

Introduction of a dedicated 24/7 emergency surgeon rota;

Recruitment of paediatric consultants providing consistent presence between 8am and

10pm every day. This enhanced consultant paediatrician cover also provided greater

support to neonatology;

Enhanced consultant geriatrician cover including surgical and elderly care patients

undergoing orthopaedic procedures;

24/7 intensive care outreach from September 2015 and enhanced intensive care

consultant cover enabling review of patients every 12 hours from January 2016;

Enhanced consultant cover on the Acute Assessment Unit;

Strengthened junior doctor arrangements and introduction of physician assistants on the

medical wards;

Enhanced consultant obstetric cover enabling 118 hours consultant presence per week

from March 2016 and additional midwives to deliver a ratio of 1:30.5 midwives to births;

Weekend pharmacy cover on the Acute Assessment Unit enabling early review of

medication requirements and supporting 7-day multidisciplinary review;

Weekend therapy support on the inpatient wards, enabling treatment plans to be in place

within 24 hours and supporting 7-day multidisciplinary review;

7-day consultant radiologist presence in place since January 2016 with extended days

during weekdays and outsourcing of CT reporting out of hours.

The Trust will continue to work towards the delivery of 7-day services with plans summarised

below:

Recruitment to vacant consultant geriatrician posts (stroke and general);

Business Case and request to Macmillian for funding to progress to on-site 7 day

palliative care provision from current 6 day a week provision.

Review of staffing structure and job planning to support 7-day consultant cover on the

medical wards.


Domain: Patient Experience

Priority 7 - Transform administration across the hospital and make

improvements in administration

Goal

Aim

Actual Performance (KHFT data used)

(2015/16)

Experience Patient letters and

GP letters (discharge

summaries & clinic

outcomes) are sent

in a timely fashion to

support on-going

care

Patients find it easier

to contact the Trust

regarding their care

and treatment

2015/16 Total complaints 465

2014/15 Total complaints: 472

2015/16 Admin related complaints: 143

2014/15Admin related complaints:113 2015-16 Clinic letters (percentage of letters completed within 10 working days): 93.42% 2014-15 Clinic letters: 84%

2015/16 Discharge summaries (sent to GPs following Day Surgery or Inpatient Episode, within 48 hours of discharge): 71.96% 2014-15 Discharge summaries: 70%

2015/16 Discharge summaries (sent to GPs following A&E attendance, within 24 hours of discharge): 93.93%

2015/16 Calls Answered: 82.49% 2014/15 Calls Answered:74%

Measure:

30% reduction in the number of formal complaints a relating to

administration

>=85% of clinic letters sent within 10 working days

>= 85% of discharge summaries sent within 10 working days Target of 75% of all calls answered in person (not answerphone)

Partly achieved


Reference for data source: Complaints received, Clinic letter data reports, Performance

data, Call centre activity data

Governed by standard national definitions? No (benchmark data not available)


It is recognised that Trust has faced significant challenges in establishing consistently

excellent and sustainable approaches to patient administration. Following devolution of

team structures out to the service lines in the autumn of 2013 there is still a high level of

complaints regarding our administrative processes and the impact this has on patient

experience.


We will build on work commenced in December 2014 with a new approach targeting the

underlying issues to improve staff engagement and cohesion across multiple work streams.

A range of indicators have been established to monitor progress. We have chosen to

monitor the following three areas:

- Patient experience as an indicator of improved administrative processes

- Letter and discharge summaries turnaround times as an indicator of both more effective

processes and improved clinical effectiveness

- Effectiveness of call handling as an indicator of improved access for patients.

How did we do?

We improved on Calls Answered in person due to the successful implementation of the

trusts new telephony system. There has been a number of changes within the administration

team which has included role definition, reallocation of roles and responsibilities into the

service lines. Now this change is imbedded we expect to see a reduction in the number of

complaints relating to administration (current data shows the trend is reducing). Overall we

have not reached our target with discharge summaries. Some areas are doing well such as

A&E, however, work needs to continue with areas that are not meeting the target. We had

expected to meet the clinic letter turnaround target, however, there have been a number of

workforce challenges which delayed progress. Currently we are running a number of

recruitment events and are optimistic this will make a significant improvement.

The Trust did not manage to reduce the number of complaints concerning administration,

although the number of PALS contacts regarding administration has seen a reduction in

year. A breakdown of the type of complaints for admin shows appointments are the main

issue. Reducing complaints regarding appointments is a priority for 2016/17.


Type of complaints about administration

Top 3 Subjects Total

Appointments 73

Communication (Incl. Consent)/information 26

Tests / Investigations 16

Top 5 Sub-Subjects Total

Unhappy with appointment bookings 16

Appointment cancellation 15

Delay in appointment being allocated 15

Poor communication with patient, relative or

carer 10

Test results / reports - failure / delay to receive 10

Priority 8 - Improve patients’ and their relatives’ experience of End

of Life Care

Goal

Aim

Experience

To establish a series of improvements for patients and their relatives based on their experiences and feedback

Measure:

Monitor the response rate to care of the dying evaluation questionnaire and deliver a communications campaign to increase response rates (15% improvement by end of year from first six months return rate)

Analysis of the themes identified by patients and their carer with the development of a programme of improvement work by August 2015

Having identified areas for improvement report on progress with improvements made as a result of feedback received

Benchmarks and KHFT data available Reference for data source: Bereavement survey

Achieved


Governed by standard national definitions? No Why did we choose this? End of Life Care helps people who are approaching death to live as well as possible until they die, and to die with dignity. It also includes support for their family or carers and includes palliative care. It is important because there is only one opportunity to get the care at the end of a patient’s life right for them and their families. We work to ensure that all patients have a dignified death, supporting their choice of where to die and working with those close to them before and after death to provide emotional and spiritual support. We work collaboratively with partner providers/ organisations to enable patients to have a ‘good death’ and to ensure that friends and family are well supported. What we said we were going to do?

Following analysis of the themes identified by patients and their carers we planned to make improvements in the following areas by August 2015

Support and care received from doctors and nurses

The control of pain and other symptoms

Communication with the healthcare team

The emotional and spiritual support provided

How did we do?

In a drive to gather representative feedback regarding the quality of care and level of support provided to the patient and their relatives or friend, the Trust used a standard validated self-completion questionnaire developed by Marie Curie: the Care of Dying Evaluation (CODE) survey. Data derived from the annual National Bereavement Survey ‘VOICES’ 2013 in which Kingston data is included within overall results, has been used as a indicative benchmark however caution must be exercised when drawing conclusions given the low response rates relevant to KHFT. The anonymised CODE survey was sent to relatives/friends during October to December

2014; 2 months or more following a death. 239 (61%) relatives / friends agreed to

participate in the survey with 80 (34%) questionnaires completed. Quantitative and

qualitative data can be drawn from the CODE survey.

Care received from the nurses and doctors

Respondents were asked about the general care the patient received from the doctors and

nurses and the environment in which this care was delivered. The questions apply to the last

two days of his/her life and related to the doctors and nurses (including healthcare

assistants and / or care agency staff) who were most involved with his/her care during this

time. Overall the above results compare similarly with the National survey results. The

results indicate

Benchmarks:


A better experience with both Nurses (3% higher than the national average; 77% vs 74%) and Doctors (6% higher than the national average; 79% vs 73%) having time to listen and discuss their condition

More people (8% higher than the national average; 68% vs 76%) said they had confidence and trust all the time in the Doctors caring for them.

The Trust is not doing as well as other trusts regarding the privacy of the surrounding bed area (4% lower than the national average; 73% vs 77%)

Feedback from both the National Bereavement, Voices and a following adapted VOICES

survey yielded a low return of 12% (n=18). Feedback was significantly higher when applying

different methodology using a standard validated self-completion questionnaire developed

by Marie Curie: the Care of Dying Evaluation (CODE) survey. The response rate form the

CODE survey sent in Q1 2015 was 34% (n=80)

The control of pain and other symptoms Respondents were asked their opinions regarding the management of symptoms the patient may have had and the care received during the last two days of his/her life. Local results are similar to the National audit, with slight improvement in symptoms managed all the time. Symptom control, however, remains an important area to focus on to improve overall experience for patients. Communication with the healthcare team Respondents were asked about the communication that they, their family members and friends received from the healthcare team who were most involved with his/her care in the last two days of his/her life. Overall the results compare favourably with the National audit with higher levels of satisfaction for explanations from the Healthcare Team. More people felt very involved with decisions about their care and treatment compared to the national picture. The emotional & spiritual support provided by the healthcare team Respondents were asked about the emotional and spiritual support that was provided to

them and their family member or friend by the healthcare team in the last two days of his/her

life. Overall the results equate to the national picture, however aaccess to Spiritual support in

the Trust is one of the themes identified from the written comments from respondents. The

Hospital Charity has approved in early 2016 an additional Chaplaincy post to support

increased access to spiritual support. Recruitment to this is underway

Overall Impressions Respondents were asked about their overall impression of the care the patient received in the last two days of life and their experiences during that time. Generally all comments were positive such as; “The treatment and care received at Kingston was absolutely excellent. I cannot envisage how it could possibly have been better. The doctors and nurses were all absolutely superb. I shall never forget them and will always hold them in the highest regard.” Themes drawn from comments demonstrate there remains some variation in care and a

continued need for improvement around general communication skills, communication

around specific sensitive issues such as nutrition and hydration and communication

A detailed action plan is now being implemented which includes extending a targeted ward based teaching programme and an updated Individual Nursing Care Plan for dying patients which aims to provide a framework to support nurses to care better for dying patients.


Priority 9 - Improved discharge planning and processes

Goal Aim

Experience

Improvements in multidisciplinary assessment of complex patients

Measure:

By quarter 4, prompt screening of all patients with complex needs by the multidisciplinary team (including physiotherapy, occupational therapy and pharmacy).

By quarter 4 a system will be in place that will enable all admitted patients to have a discharge plan and estimated date of discharge as soon as possible (within 24 hours)

Reference for data source: Patient records and coding

Governed by standard national definitions? Yes


This priority is based on implementation of the London Quality Standards. It focuses on improving multidisciplinary assessments for the complex patient and safe, timely and appropriate discharge from hospital for all patients. This builds upon the 2014/15 7 day working CQUIN to improve standards, patient outcomes and experience. Primary, community and social care partners are recognised as key to the delivery of consistently high quality discharges 7 days a week, therefore our Community partners have a similar CQUIN to support the integration of discharge teams and processes.


By Q4, there will be prompt screening of all patients with complex needs by the multidisciplinary team (including physiotherapy, occupational therapy and pharmacy).

By Q 4 a system will be in place that will enable all admitted patients to have a discharge plan and estimated date of discharge as soon as possible (within 24 hours)

How did we do?

We have achieved both objectives. We have developed a tool called the Patient Tracking

List Tool, which allows us to manage every “wait” a patient has, from the start of acute

treatment until they are discharged as either a simple or complex discharge.

These plans are developed on the arrival on the ward, and are updated daily as a result of the daily patient (RAG) round. The DISCO IT system shows the discharge status of patients day-to-day and so used on the wards and at the daily bed meeting. It is also informs the weekly review of all “stranded” patients (i.e. whose length of stay is over 7 days) and at the weekly Delayed Transfer of Care discussion and agreement meeting with our health and social care partners. When estimated discharge dates have not been identified there will be clear reason/plan (with a review date) to ensure one is determined as soon as possible. We recognise there is more to do in improving the experience of discharge and we are pleased this is a quality goal for 16/17.

Achieved


6.0 Other Improvements to Quality of Care at Kingston Hospital In the course of selecting our priorities and indicators each year, we focus on areas where there is improvement required, but in this section we want to highlight some of our other areas of focus and performance. For this report we have chosen to summarise our improvements within the 5 CQC domains – safe, effective, responsive, caring and well led.

Safe Sign up to Safety

Sign up to Safety is a national patient safety campaign. Kingston signed up in December

2014, submitting 3 Safety improvement Projects. Sign up to Safety aims to deliver harm free

care for every patient, every time, everywhere. It champions openness and honesty. The

Trust is implementing 3 safety projects:

1. Eliminate all avoidable deaths from severe sepsis and septic shock by December

2018. To reduce harm by ensuring that the Sepsis 6 Interventions are achieved for

90% of patients in hospital, within one hour of identification of severe sepsis or septic

shock.

2. Reduce avoidable, hospital acquired grade 2, 3 and 4 pressure ulcers by 10% by

March 2018.

3. Reduce harm by introducing intrapartum fetal wellbeing assessment and

management in high risk pregnancy

Maternity The unit is taking part in Sign Up to Safety (SUTS) and aiming to reduce harm by introducing intrapartum fetal wellbeing assessment and management in high risk pregnancy Two dedicated fetal surveillance midwives are running a project to provide enhanced teaching on Cardiotocography (CTG) interpretation. The aim of the project is to reduce poor outcomes related to misinterpretation of CTGs and to increase staff competency in CTG interpretation. Progress so far:

Successful bid submitted to NHSLA to secure funding for 1 year in the region of 250k.

Audits and case note reviews completed.

The maternity SUTS team have organised 2 Master classes and 120 midwives in total so far have attended.

Development of competency Assessment for all staff.

Weekly CTG reflection workshop held for all members of staff. Lunch and refreshment is provided to encourage staff to attend.

Bed side teaching on daily basis to increase knowledge of interpretation of CTG.

Reflection and reviewing performed on daily basis by SUTS midwives of cases with admission to the Neonatal Unit and emergency deliveries.

There is daily teaching of the band 7 midwives in the unit.


Pressure Ulcer Prevention No patient should develop pressure ulcers whilst in hospital and there has been a number of initiatives nationally and locally to prevent avoidable pressure ulcers over the past few years. Pressure ulcer prevention is one of the Trusts Sign up to safety improvement projects. The aim of the project is to reduce avoidable, hospital acquired grade 2, 3 and 4 pressure ulcers by 10% by March 2019.

The pressure ulcer strategy (pictured below) was launched on the 19th November 2015 on International Stop Pressure Ulcer Day. A stand was set up at the main entrance Patient Information leaflets were available and were given out to staff and members of the public with verbal explanation about pressure ulcer prevention.

Diagrams of the stages of pressure ulcers were also displayed on the display boards Patient Information leaflets have now been distributed for use on the inpatient wards.

Pressure Area Management Policy and the Wound care Policy reviewed.

A new Pressure Ulcer Investigation form has been devised which is used for all stages of ward acquired pressure ulcers.

Training continues on the use of incontinence products in adult inpatient wards.

The wound care study days have been re-commenced. They are running in December, and January and then every 2 months thereafter.

Ward based training has commenced on Derwent ward. Hourly sessions cover identification and categorisation of pressure ulcers, preventative measures, identification of moisture lesions and accurate documentation. Training planned for AAU.

The impact of the work has been significant with an overall reduction in grade 2 pressure

ulcers by 42.3%, and no stage 4 pressure ulcers reported in 2015 -16, compared to 3 in

2014 – 15.

The pressure ulcer strategy


Quality Improvement Projects The Trust’s Quality Improvement Project programme has continued to grow during the year,

with progress monitored through the Quality Improvement Working Group. The programme

includes the Trust’s three Sign Up to Safety projects, as well as other topics led by various

clinical teams.

One project completed this year concerned the prescribing of oxygen. A national clinical

audit had shown that Kingston Hospital, along with most other hospitals in the country, did

not always write a prescription for oxygen when required. This is important since oxygen is

a drug and oxygen levels should be carefully monitored to ensure patients received neither

too much nor too little oxygen. The project, led by a Consultant Respiratory Physician,

entailed writing a new oxygen policy, providing education and training to clinical staff and

producing visual reminders, such as ‘oxygen magnets’ for the patient’s bed space. Our

national clinical audit results have risen from 15% in 2013 to 66% last year. Oxygen

prescribing is still being monitored to ensure that our results improve even further.

Duty of Candour The Trust asked the internal auditors to carry out an audit of Duty of Candour to assess the

systems we have been put in place, When patients have been harmed during care this is

recorded on our incident reporting system and triggers the Duty of Candour process.

Patients will receive an apology and then feedback on why this happened and support with

aftercare and follow up. More guidance for patients and staff is now being developed to

support patients through the process and ensure staff understand how to keep patients

informed during an investigation.

Effective

CHKS Top 40 Hospital Award In May 2015 the Trust was named as a CHKS Top 40 Hospital for the 15th year in a row, and is the only Trust to have achieved this. Intensive Care Unit Within the Intensive Care Unit, a passive exercise machine has been introduced and provides early implementation for this group of patients and has reduced their length of stay. During the autumn of 2015 the Trusts Outreach team was expanded to provide a 24 hour, 7 day a week service. This means patients who are identified as requiring additional support, due to deteriorating observations, have access to a critical care nurse 24/7. This enables a more rapid review of deteriorating patients and support to ward based staff.


Hip fracture pathway improvements

Trauma & Orthopaedics has worked to improve the hip fracture care pathway. On admission

to the Emergency Department, patients will be routinely offered fascia iliaca block (FIB is a

local anaesthetic block to reduce pain) as soon as possible after diagnosis of a hip fracture.

Each emergency fractured neck of femur operation will be prioritised on a planned

emergency trauma list and the operation undertaken within 24 hours of admission or

diagnosis; and an estimated discharge date will be set within than 24 hours. Post operatively

all patients will have hourly National Early Warning Scores (NEWS) for the first four hours,

and will be reviewed by a doctor and the nurse in charge, within 4 hours of their return to the

ward. Following implementation of our hip fracture pathway improvements the results in

Quarter 4 were:

96 % of patients were offered an FIB.

84% of patients had their operation for their hip fracture within 24 hours .

77% of patients were received hourly NEWS and a review at 4 hours.

77% of patients had an estimated discharge date set.

Smoke Free Site During 2015 we the Trust went Smoke Free across the site. It was important that we provide support to staff, patients and visitors via smoking cessation clinics and availability of treatments like Nicotine Replacement Therapy. Inpatients now have quick access to treatment and are offered a referral to a stop smoking specialist on discharge. The wards also stock nicotine replacement products. We worked closely with the Royal Borough of Kingston and the local community to ensure residents were informed and their concerns addressed. Where there used to be a smoking shed there is now a bike shed. We will build on this positive development to further promote healthy choices to staff, patients and visitors.


Caring

Dementia In January 2016 the Alzheimer’s Society launched its report ‘Fix Dementia Care Hospitals’ report from the Trust. Within the report the Trusts work on its dementia strategy and the subsequent changes that had been implemented were featured as a case study of good practice. Picture of an Activities Session

End of Life Care The End of Life Care team were one of the first to respond to the withdrawal of the Liverpool Care Pathway and developed a plan which informed the national approach to nursing and care at the end of life and has been adopted by a number of other organisations. The teams were shortlisted for a National Patient Safety award in July 2015. Whose Shoes The Trust has continues to hold Whose Shoes workshops during the year, to focus on improving the experience of patients and staff. This has included sessions in maternity, theatres, pediatrics and the day surgery unit.


Children & Young Persons survey The National NHS Children’s and Young person’s (CYP) Inpatient and Day Case Survey

2014 at Kingston Hospital NHS Foundation Trust undertaken by the Picker Institute key

findings showed:

91% of parents rated care 7 or more out of 10

93% of children and young people rated care 7 or more out of 10

90% of parents felt their child (aged 0-7 years) was always safe on the ward

89% of children and young people (aged 8-15 years) always felt safe

58% of parents of children aged 0-7 years stated there were definitely appropriate

things for their child to play with on the ward, whereas 30% of young people aged 12-

15 years felt there was a lot for their age group to do,

81% of parents always had confidence and trust in the members of staff treating their

child (0-15 years)

88% of parents stated they were always treated with dignity and respect by the

people looking after their child (0-7 years).

The survey results showed that the majority of our results were in line with the average for

other trusts; with the following areas being significantly better than the Picker average in that

the staff were always available when child needed attention, members of staff caring for the

CYP worked well together as a team, staff were friendly and that parents felt they were

listened too. Areas for improvement where our results were worse than the Picker average

were that children did not completely like hospital food and Young People were not fully

involved in decisions about their care and treatment.

The actions we have taken in response to this survey are that we have implemented a new

menu with Children and Young Peoples involvement. A local charity have provided funding

to refurbish the teenage room on the inpatient ward and free Wi-Fi is now available for all

CYP in the Paediatric inpatient ward. We have actively engaged with Kingston Health Watch

and a Young person’s group have visited the Paediatric inpatient and A&E areas to provide

feedback. FFT CYP questions are available, ensuring we are now receiving the feedback

from CYP about their care. We have an established trust wide CYP board with

representation from a young person a parent and all areas that see and treat children and

young people.

Maternity Survey The findings of the maternity survey for women who gave birth in February 2015 reported

back in December 2015. As in previous surveys, Kingston Maternity unit was ranked the

best in London for labour care. There are some areas which require improvement,

particularly around continuity of care from the same midwife throughout pregnancy and the

post natal period. An action plan has been developed which has been shared with the

Maternity Services Liaison Committee. The ante natal and community midwifery teams have


been reconfigured to offer more continuity and further work is planned around IT access in

community clinics and children centres to enhance continuity for women and midwives.

Neonatal Survey The Trust commissioned Picker to undertake a survey of the experience of parents within

the neonatal unit at Kingston Hospital. In response to this improvements have been made to

the breast feeding facilities on the Neonatal Unit. Headphones are now available for parents

during ward rounds, which allow parents to stay with their babies, and protect confidential

discussions with other parents.

Responsive Improving the hospital environment In line with the Trusts estates plan, there has been continued development of the hospital for the benefit of patients and staff. One of the most significant of these projects was the complete replacement of the windows in Esher Wing. This has improved the experience of patients and staff in this building through better temperature control and the aesthetic created. The ‘Daisy room’ was, thanks to charitable donations, opened in year. This provides a dedicated bereavement suite in the maternity unit. Thanks to the work of Momentum the paediatric A&E waiting area has also been redecorated to create a friendlier environment for children & young people. Work has also commenced on the children’s area of the Royal Eye Unit. This is part of improvements which are being taken forward as a result of the Trusts Children & Young Peoples Board, focus on improving care for children & young people wherever they are seen within the Trust. The refurbishment of the main outpatients department is underway and unfortunately delays to the building programme have meant it was not completed in 2015/16 as planned. The new department will include a completely redesigned waiting area and a new location for phlebotomy to help improve the patient experience. This will open in 2016/17 and enable a better experience for patients using this service. The new purpose build transport lounge opened in March 2016 enhancing the experience of those patients waiting transport. In April 2015 the Paediatric Assessment Unit (PAU) opened providing a 7 day service from 8am to 12pm each day. Cancer The Trust has made significant improvements in its cancer waiting time performance during 2015/16. In the last 4 months of 15/16 we have consistently been above the national average for 62 day treatment (2week wait) performance and currently (April 2016) the best performing Trust in London, on this indicator. We had no hundred day breaches for five consecutive months, which no other Trust in South West London achieved this. Within the breast, dermatology and plastics services there has been significant improvements in the waiting times for patients with suspected breast cancer and the Trust is


now meeting all the national cancer waiting times targets. The department has also appointed Advanced Nurse Practitioners as part of service redesign. Cancer targets User involvement: We have re-invigorated our Cancer Service User Group and meet bi monthly with a number of ongoing projects including:

Reviewing new cancer patient information

Assisting with real time feedback

Improving the Website

Participating in the build and design of a Hematology Day Unit in the William Rous Unit

Indicator Standard 2015/16

Performance RAG*

All cancers: 62-day wait for first treatment from:

- urgent GP referral for suspected cancer greater than or equal to 85%

90.7%

- NHS Cancer Screening Service referral greater than or equal to 90%

97.7%

All cancers: 31-day wait for second or subsequent treatment, comprising:

- Surgery greater than or equal to 94%

98.6%

- Anti cancer drug treatments greater than or equal to 98%

100%

All cancers: 31-day wait from diagnosis to first treatment greater than or equal to 96%

97.4%

Cancer: two week wait from referral to date first seen, comprising:

- all urgent referrals greater than or equal to 93%

95.3%

- for symptomatic breast patients (cancer not initially suspected)

greater than or equal to 93%

95.0%

Data source: National Cancer Database

*RAG stands for Red, Amber Green Complaints There has been a slight decrease in complaints during 2015/16 as shown in the table below.

Total complaints 2015-16

Total complaints 2014-15

465

472

We recognise that swift action is key to resolving complaints and, as such, we endeavour to respond to all complaints within 25 working days, or by the timeframe agreed with the complainant. There has also been a significant and sustained improvement in our response


rate, and the overall compliance for 2015/16 is currently 82%. (excluding March 2016 as the response rate cannot yet be measured for the complaints received in March 2016). Complaints response rates:

Patient and Public Involvement Strategy 2016-18

Following a further period of engagement with key stakeholders the Strategy has been

refreshed for 2016-2018. The refreshed strategy adds two further pledges to reach

marginalised groups and help the public to navigate the multiple ways they could be involved

with the Trust. Specific reference had been made to the importance of working with

Healthwatch to support reaching marginalised groups particularly.

The PPI functions had been defined to assist understanding but also to identify further focus

for groups with no voice or seldom heard. The six pledges from the previous strategy had

also been updated and an additional pledge added.

Healthwatch Enter and View Visits 2015-16 We work closely with Healthwatch Kingston, Richmond and Wandsworth. A number of Enter and View visits by Healthwatch Kingston have taken place during 2015-16. A summary of the main findings, recommendations and actions are shown below: Emergency Department (ED) - March 2015 The main focus of the visit was the patient’s experience of the emergency department. This covered waiting times, reasons for attending, communication and quality of care. The overall feedback the Trust received was positive, with a view to return to the department within 6-8 months. Main recommendations included::

• Clear signage • Information about waits • Access to alternative toilet facilities


Actions taken following the visit include:

• Signage improved highlighting where alternative toilets can be found within the department.

• Introduction of clear information on expected waiting times on the ED Reception’s patient information screen.

• Monitoring of hand sanitizers in the cubicles to ensure they are available. Two further visits took place (one day/one evening) 25th & 26th February 2016 in the Emergency Department Reception and Minors. Again the overall feedback was positive and the recommendations from these visits are being devised into action plans. Royal Eye Unit - July 2015 The focus of visiting the Royal Eye Unit (REU) was to gain an insight into the service being provided and how it is experienced by patients. Representatives from Healthwatch gathered information by talking to patients, completing patient questionnaires and recording observations about the environment. The overall feedback was positive. The main findings were:

• 87% of patients said their communications about appointments had been efficient. Patients commented they were happy with the timing of the letters they received and the information was clear.

• All of the patients asked said they found the reception staff and nurse they saw friendly and helpful.

• The majority of patients asked said the waiting area was comfortable and pleasant. Main recommendations included:

• Clear communication with patients in reception. • Communicate name and role to patients. • Signage for the visually impaired.

Actions taken following the visit:

• A hospital wide project is looking at how we can improve signage for our visually impaired patients and visitors.

• The development of a volunteer network within the unit. Paediatric wards and Paediatric Emergency Department - August 2015 The visit was led by children and young people. They were impressed by the wards and departments in terms of the decor, the cleanliness, the staff and the facilities. They were keen to give feedback on the new food menu and agreed that the new graphics were eye catching. The introduction of a more snack-based lunch option was popular. The main recommendations following the visit were:

• Provide a more comfortable temperature on the wards and entry areas • Improve lighting where possible in darker areas • Provide newer toys to replace those that are old and dated • Ensure hand sanitizer pumps are always full

Action and Follow up There was a follow-up visit to Paediatric wards and Paediatric Emergency Department. This found that the Teenagers’ Room and Children’s Emergency Department were greatly improved with redecoration and the action items from their last visit in had been implemented. Inpatient Wards – November/December 2015


Healthwatch Kingston and Healthwatch Richmond worked together to carry out these visits. They visited five inpatient wards. They chose specific wards based on information from PALS reports. They visited Blyth, Bronte, Hamble, Hardy and Keats. Their main focus was around the patient’s experience of care, staff, decisions about care, cleanliness, food, and discharge arrangements. The main feedback was positive. Overall the wards were clean and staff were friendly. The patient experience of care on the wards was good. Patients were generally satisfied with the meals. The main recommendations following the visit were:

• Consider simplifying choice on menu cards and introducing fortnightly cycle • Introduce wider range of wholemeal foods for vegetarians • Ensure all patients are aware they can have hot drinks whenever they want • Ensure that the full next of kin/patient representative information is accessible to staff

at all points on a patient’s journey, by modifying the formatting of the information on the IT system

• Ensure there is a room available for private discussions • Inform/reassure elderly, vulnerable patients as early as possible about carers/help at

home schemes upon discharge Discharge from Hospital Report Between July 2015 and January 2016, Healthwatch Richmond carried out an extensive project to look at how patients experience being discharged from local hospitals. The findings were published in April 2016. The main recommendations relevant to Kingston were:

• Ensure that patients are kept informed about their discharge. • Information about Teddington Memorial Hospital is given to patients being transferred

there. • Provide patients who live alone with additional support to transition more successfully

from hospital to the home. • Improve communication between services, particularly with GP practices and

community care staff. • Review the provision of equipment for patients in the home. • Provide more than 24 hours’ notice to community nurses on equipment that they

need to order for patients due to be discharged. • Look at the length of time it takes for pharmacy to deliver medications to patients

being sent home. • Hospital to review the provision of non-emergency patient transport.

The Hospital has reviewed and responded to the recommendations and are working closely with other partners to look at the challenges we face around discharge and what improvements we can make to the process.

Improvements to hospital food The Trust continues to make improvements to food for patients and feedback is now more positive. Here are some of the key improvements during 2015/16:

• Pictorial menus have been designed to assist patients with any kind of communication difficulty to make their own meal choices

• For those patients with dementia who are too restless to sit down and eat at mealtimes or for those who are no longer able to manipulate cutlery, we have introduced the Finger Food menu; this comprises a complete picnic meal in an easily portable box containing foods to trigger reminiscence


• Patient Food Discharge Packs are another innovation, designed for patients who are being discharged home to an empty house; these packs will supply sufficient foods for a ‘no cook’ meal together with beverages to help the patient settle back home

• The hospital runs a Lunch Club for in patients within elderly care • Volunteer Dining Companions have continued to expand in numbers and they

provide assistance with patient meals. All our Dining Companions are trained to a basic level and some go on to more specialist training run by speech & language therapists and dietitians. The higher level of training enables our Dining Companions to be able to assist feed some of our more vulnerable patients

• Launched a new specially designed menu for Sunshine and Dolphin Wards (Children & Young peoples wards) - for those children and young people who are able to leave the ward area, food vouchers are provided to enable them to eat in the Trust Restaurant with their family

• The maternity Unit has already launched a new plated meal service giving greater flexibility of meal timings to new mothers

• Toast is now available and cooked breakfasts are offered at the weekend

Picture of childrens menu launch


Well led Volunteers 2015-2016 has been a year of realising the true impact of volunteers across the Trust. This

is the culmination of the Trust’s participation in the Centre for Social Action’s ‘Helping in

Hospitals’ programme with Nesta and the Cabinet Office. In 2016 the Trust welcomed the

1,000th volunteer into the Volunteering Programme. This has enabled established

programmes such as Dining Companions, Dementia Volunteering, Chaplaincy, Welcoming

and Hospital 2 Home Volunteering to flourish with regular coverage across the wards and

departments that need their support. As a result, the Trust and volunteers can be certain

their time is enhancing patient experience. This year, volunteers have helped to:

Improve patient satisfaction at mealtimes by 5%

Reduced anxiety amongst older patients at discharge by 48%

Improved the mood and wellbeing of patients with dementia by 42%

Connected more than 50% Hospital 2 Home patients to local charities and support groups

We are very proud to report that our Friends & Family Test has demonstrated a clear overall

relationship between the support that patients receive from volunteering, and their overall

satisfaction with their experience at Kingston Hospital.

The Trust has established relationships with Kingston College Access to Midwifery

programme, Richmond College’s Project Search, Esher College and sixth forms across local

boroughs to create volunteering opportunities for young people and mature students aspiring

towards careers in medicine, nursing, health care and health service administration. This has

changed the way that we welcome younger volunteers aged 16 – 21 into the Trust who

receive an unprecedented insight into hospital life through practical volunteering and

intensive support from clinical and non-clinical staff.

Volunteers have influenced ongoing improvements and their unique perspectives are

shaping the way the hospital is run. The Quality Improvement Volunteers have supported a

wide range of projects including the Pressure Ulcers Strategy, Sepsis Awareness Campaign,

Dignity at Night and helped to shape the Trust’s Corporate Objectives. New forums such as

‘Come Dine With Me’ brings volunteers face-to-face with the staff and contractors who lead

the Food & Nutrition Strategy to inform the ongoing improvement of menus and patient

experience at mealtimes.

New volunteering programmes in A&E and the Maternity Unit see volunteers and staff

working closely together to improve patient experience within a busy and often challenging

clinical environment.

The Trust’s Volunteering Service was awarded the Kingston Quality Mark accreditation from

Kingston Voluntary Action. This is a new quality assurance tool devised by Kingston First,

Kingston Voluntary Action Group and advised by Stay Well, Help the Hospices and Kingston

Hospital as a way to:


Reward and recognise good practice in volunteer management across the Borough Support small charities and organisations to follow best practice models with case

studies and practical guidance Enable the public to make informed decisions about where they invest their time as

volunteers Stand out as a Borough that celebrates volunteering as an asset of its community

and way of life

Governance Review A Well Led Review conducted by an independent organisation in November 2015 concluded that the Trust has sound governance processes and structures in place. Foundation Trusts are required to carry out an independent review against Monitor’s Well

Led framework for governance every three years. The review is an assessment of the

Trust’s leadership and governance capacity across ten domains allied to the CQC inspection

framework in four broad categories: strategy and planning; capability and culture; process

and structure; and measurement. As 2016 marked the third year since Foundation Trust

status was granted, KHFT commissioned Capsticks Governance Consultancy Service to

carry out a Well Led review during the period September to November 2015. The review

included observations of meetings, consultation with patients, staff and stakeholders,

questionnaires and interviews with individual members of the Board. The key overall

findings from the final report were “that Kingston Hospital NHS Foundation Trust is well led

by the Board and that the governance processes and structures are sound and appear to be

working well including those relating to performance management”.

The review identified some areas of outstanding practice and many areas of good practice,

with areas identified for further attention being primarily developmental. No material

governance concerns were found. Capsticks highlighted that patient safety and quality were

evident as the Trust’s priority, saying “There is a strong quality culture led by the Board and

leaders throughout the organisation prioritise safe, high quality, compassionate care”. The

evidence was based on observations at Board and Committee meetings, patient safety and

quality featured strongly during interviews with Board members and as a key theme in

discussions with staff.

NHS Staff survey

In the 2015 NHS staff survey published in February 2016, there were significant improvements in scores across a number of areas compared to the 2014 survey including recommending the Hospital for treatment and as a good place to work.

The Trust scored in the Top 20% of Hospitals across the country in a number of areas including:

• Staff reporting good communication between senior managers and staff; • Number of staff receiving an appraisal; • Support from immediate managers; • Staff believe their role makes a difference to patients; • Low levels of physical violence from patients, relatives and visitors; • Staff feel able to contribute to improvements at work;


• Recognition of work by managers; • Effective team working; • Effective and fair processes for reporting incidents; • Effective use of patient feedback.

We are also required to report on the following indicators from the NHS staff survey (2015)

Key Findings 26: % experiencing harassment, bullying or abuse

from staff in last 12 months

Kingston Trust in 2015 Average score: 29

(median) for acute trusts 26

Key Findings F21:. % believing the organisation provides equal opportunities

for career progression / promotion

Kingston Trust in 2015 Average score: 82

(median) for acute trusts: 87

We have continued to focus on improving the working lives of our staff from the Black, Asian and Minority Ethnic (BMAE) Community and also looking at why we have higher than average number of staff reporting they have been bullied or harassed by other staff. For 16/17 we have set a specific corporate objective to improve the day to day to experience of BMAE staff in the Trust. Introduction of Schwartz rounds In May 2015 the Trust held its first Schwartz Round. Developed by the Boston-based Schwartz Center for Compassionate Healthcare these are a multidisciplinary forum where staff come together once a month to discuss and reflect on the, the emotional and social challenges in their roles. Compassion from staff is essential to patient wellbeing. For staff to provide compassionate care, they need to feel supported in their work. Rounds are designed to provide this support. Rounds aim to improve relationships and communication in teams and between staff and their patients. The rounds are structured around themes with a small number of speakers talking about their experiences with a facilitator overseeing the round and getting feedback from the wider audience. There has been excellent feedback from staff that shows they find the session’s valuable and thought provoking.

7.0 Overview of Services

During 2015/16 the Kingston Hospital NHS Foundation Trust provided and/or subcontracted 44 relevant NHS services, for adults and children as follows: These services covered the following specialities: Accident and Emergency

Assisted Conception

Cancer

Cardiology

Ear, Nose and Throat

Gastroenterology and Endoscopy

General Medicine

Genito Urinary Medicine


Care of the Elderly

Clinical Support Services – therapies related to an inpatient episode of care and/or referral for outpatient treatment(s)

Community Midwifery

Community Paediatrics

Critical Care

Diabetes and Endocrinology

Diagnostics (imaging and pathology)

Dietetics

Digital Hearing Aids

Direct Access – Pathology

Direct Access – Blood Transfusion

Direct Access – Cytology (gynaecology)

Direct Access –

Cytology (non-gynaecology)

Direct Access – Haematology

Direct Access – Histopathology

Direct Access – Immunology

Direct Access – Microbiology

Direct Access – Radiology/Imaging

General Surgery

Gynaecology

HIV

Neonatal Care

Obstetrics

Ophthalmology

Oral and Dental Services

Paediatrics

Pain Management

Parent Craft

Patient Transport

Physiotherapy outpatient

Respiratory Medicine

Rheumatology

Surgical Appliances

Urology

Trauma and Orthopaedics

The Trust has reviewed all the data available to it on the quality of care in 44 of these relevant health services. The income generated by the relevant health services reviewed in 2015/16 represents 88.14% of the total income generated from the provision of relevant health services by the Trust for 2015/16.

8.0 Monitor Risk Assessment Framework Monitor is the regulator for Foundation Trust health services in England. They exercise a range of powers granted by Parliament which include setting and enforcing a framework of rules for providers and commissioners, implemented in part through licences they issue to NHS-funded providers. As part of their role, Monitor has an assessment process which is called a Risk Assessment Framework. The purpose of the framework is to show through a rating system when there may be cause for concern at an NHS foundation trust about financial sustainability or governance. It is important to note that the ratings will not automatically indicate a breach of licence nor trigger regulatory action. Rather, they will prompt Monitor to consider where a more detailed investigation may be necessary to establish the scale and scope of any risk.


The risk rating for the Trust at the end of 2015/16 indicates no evident grounds for concern and that Monitor is not currently undertaking a formal investigation. The table below shows our overall rating for the last year. Monitor Governance Risk Rating – Performance against national measures

Kingston Hospital NHS Foundation Trust regulatory rating 2015/16 (Monitor)


Under the Compliance Framework (replaced by the Well Led Framework)

Governance risk rating

Green Green Under review Under review To be confirmed

Financial risk rating (COSSR)

2 2 2 2 To be confirmed

In July 2015 Monitor’s opened a formal investigation into the Trust’s compliance with its

licence in regards to Cancer, Finance and A&E. In December 2015 Monitor closed the

investigation without formal regulatory action, which was replaced by informal monitoring

and support to ensure ongoing sustainability in both finance and performance.

Monitor – Summary of operational performance

Indicator Threshold Weighting

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Maximum time of 18 weeks from point of referral

to treatment in aggregate - patients on incomplete

pathway

92% 1.0 0 0 0 0 0 0 0 0

A&E: Maximum waiting time of four hours from

arrival to admission/transfer/discharge95% 1.0 0 0 1 1 1 1 1 1

- urgent GP referral for suspected cancer 85%

- NHS Cancer Screening Service referral 90%

- Surgery 94%

- Anti cancer drug treatments 98%

All cancers: 31-day wait from diagnosis to first

treatment96% 1.0 0 0 0 1 0 0 1 0

- all urgent referrals 96%

- for symptomatic breast patients (cancer not

initially suspected)93%

Clostridium (C.) Difficile (due to lapses in care) -

meeting the C. Difficile objective

(2014/15)

24 per annum

(2015/16)

9 per annum

1.0 0 0 0 0 0 0 0 0

Certification against compliance with

requirements regarding access to healthcare for

people with a learning disability

N/A 1.0 0 0 0 0 0 0 0 0

3 1 2 5 2 1 2 1

Data source: KHFT Quarterly Monitor Returns

1.0

2014/15 2015/16

0

0

1 1 1 1

1 10

01 0 0 1

Total score

0 0 0

0 0 0

1 0 0

Cancer: two week wait from referral to date first seen, comprising:

1.0

All cancers: 31-day wait for second or subsequent treatment,

comprising:

1.0 0

All cancers: 62-day wait for first treatment from:


9.0 Participation in Clinical Audits

Clinical audit is designed to improve patient care, treatment and outcomes. Its purpose is to

involve all healthcare professionals in a systematic evaluation of delivery of care against

evidence based standards, identify actions to improve the quality of care and deliver better

care and outcomes for patients. The work carried out by the various National Confidential

Enquiries involves review of patient care nationally. The resulting recommendations enable

local hospitals to drive up standards and enhance patient care and safety.

At the start of 2015/16, 36 national clinical audits and 3 national confidential enquiry

programmes covered NHS services that Kingston Hospital NHS Trust provides. During that

period Kingston Hospital NHS Trust participated in 89% (32/36) national clinical audits that

have started to date and 100% per cent of national confidential enquiry programmes of the

national clinical audits and national confidential enquiry programmes (Appendix 1) which it

was eligible to participate in.

The national clinical audits and national confidential enquiries that Kingston Hospital NHS

Trust was eligible to participate in during 2015/16 and for which the data collection was

completed during 2015/16, are listed in Appendix 2 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.

The reports of 23 national clinical audits, applicable to Kingston Hospital, were published

during 2015/16 and of these 17 were formally reviewed during 2015/16 (the remainder

awaiting review). The actions we intend to take to improve the quality of healthcare are

included in Appendix 3.

The reports of 150 local clinical audits were reviewed by Kingston Hospital NHS Foundation

Trust in 2015/16. Examples of improvement actions taken as a result of national and local

audit are shown in the table below.

Clinical audit results are discussed at clinical meetings in local departments and at wider

meetings such as the Trust’s annual Clinical Audit Seminar. The results of both national and

local clinical audits are used to drive local quality improvement. More detailed information

about the actions we have taken from clinical audit will be available in our Clinical Audit and

Effectiveness Annual Report, via the Medical Director’s department, from July 2016.

National and local clinical audit results are used by Kingston Hospital to both assure itself of

the quality of patient care and improve care where gaps are found. Four examples of how

clinical audit results have provided assurance and improved care during 2015/16 are given

in the boxes below.

Clinical audit providing assurance

National audit The Trust has taken part in the National Bowel Cancer Audit for a number of years and the most recent report published in December 2015 contained results for 138 Kingston patients with

Local clinical audit Whilst the prescribing of drugs is usually within the remit of a doctor, a number of Kingston Hospital’s nursing staff are able to prescribe drugs, having undertaken and passed a prescribing course. To


comparisons to the national average. Kingston’s two year mortality rates (observed and adjusted) were both well below the national average of 22%, at 15% and 16.9% respectively. Our 90 day readmission rate was also much lower than the national average, with our adjusted rate 12.4% compared to the national average rate of 19.9%. The national audit data is reviewed regularly throughout the year by the Colorectal team.

ensure that this prescribing is carried out safely, a peer review audit was conducted by the nurses themselves during 2015 of over 100 prescriptions. The prescriptions were assessed for the type of drug prescribed, its dose, frequency and duration. The audit found that all nurse prescribers were prescribing within their capacities to a high standard, with good record keeping demonstrated.

Clinical audit driving improvement

National audit Clinical data submitted to the National Emergency Laparotomy Audit has been used at Kingston by clinicians from Anaesthetics, Surgery and ITU to make substantial improvements to patient care over the past year. This involved the implementation of a clear care pathway for patients undergoing emergency laparotomy surgery, including increased consultant input and admission post operatively to ITU, as well as the appointment of new Elderly Care doctors for Surgery to ensure timely patient assessment. The 30 day mortality rate for Kingston hospital in 2015 was 5.9% compared to the national average of 11%.

Local clinical audit Handover of care between wards is very important for patient care, both in terms of safely and patient progress. The post natal wards have used local clinical audit to drive improvement over the past year in raising standards in patient handover. They performed audits monthly against the hospital’s guideline on Handover of Care to track progress, increasing their use of the SBAR tool (Situation, Background, Assessment, Recommendation). Improvements were made through staff training and engagement.

10.0 Participation in Clinical Research The number of patients receiving NHS services provided or sub-contracted by the Trust in

2015/16 that were recruited during that period to participate in research approved by a

research ethics committee was 205 (portfolio studies only).

The Trust was involved in conducting 8 clinical research studies during 2015/16

There were 34 clinical staff participating in research approved by a research ethics

committee at the Trust during 2015/16. These staff participated in research covering 8

specialities.


11.0 Use of the CQUIN Payment Framework

A proportion of income for Kingston Hospital NHS Foundation Trust in 2015/16 was conditional on meeting quality improvement and innovation goals agreed between Kingston Hospital NHS Foundation Trust and commissioners, Clinical Commissioning Groups, through the Commissioning for Quality and Innovation (CQUIN) payment framework. Further details of the agreed goals for the reporting period are provided in the table below. The CQUIN goals for 2016/17 are yet to be finalised with the commissioners. The key aim of CQUIN is to support a shift towards a vision where quality is the organising principle. The framework therefore helps ensure that quality is always part of discussions between commissioners and hospitals everywhere. In 2015/16 the Trust had a contract value of £4,133,602 for CQUIN activity (in the previous year, the value of this activity was £ 4,157,145). The table below illustrates how the Trust performed against the CQUIN schemes.

National CQUIN Achievement 60%

Local CQUIN Achievement 100%

*GRAND TOTAL £4,133,602 £3,550,764 86%

*Provisional results as final data not available at time of publishing The table below summarises the different CQUIN schemes that the Trust engaged in:

Theme Aim

National CQUIN 1. Acute Kidney Injury

AKI diagnosis and treatment in hospital and the plan of care to monitor kidney function after discharge, measured through the percentage of patients with AKI treated in an acute hospital whose discharge summary includes each of four key items of information listed below:

1. Stage of AKI 2. Evidence of medicines review having been undertaken 3. Type of blood tests required on discharge for monitoring 4. Frequency of blood tests required on discharge for monitoring

CQUIN achievement 55%

National CQUIN 2. Sepsis

Incentivise providers to screen for sepsis all those patients arriving in hospital via the Emergency Department (ED) for whom sepsis screening is appropriate, and to rapidly initiate intravenous antibiotics, within 1 hour of presentation, for those patients who have suspected severe sepsis, Red Flag Sepsis or septic shock.


National CQUIN 3. Dementia

(a) Find, Assess, Investigate & Refer (b) Clinical Leadership (c) Monthly Audit of Dementia carers

CQUIN achievement 40% Elements b & c fully achieved

Local CQUIN 4. South London Collaborative CQUIN Strategic Data Set

In line with commissioners’ 5 year strategic plan, to establish a common process of collecting data for following strategic datasets (a) Children’s dataset- PAU (b) AEC (Ambulatory Emergency Care) dataset


(c) Integrated Care- A&E discharge (d) SWL Acute Data Set - Integrated Care 2 (DTOCs)


Local CQUIN 5. South London Collaborative CQUIN Inter-hospital Transfer

(a) Establish a SW London inter-hospital transfer network to coordinate and resolve issues relating to clinically indicated transfers (b) Establish means of monitoring and reporting compliance with IHT standards (c) Full achievement of each of the adult and paediatric inter-hospital transfer London Quality standards by the end of Q4 2015/16


CQUINS for 2016/17

The total value of 2016/17 CQUINs is approximately £3.99 million

Local CQUIN 2016/17

Local CQUIN goals for 2016/17 were not finalised with commissioners at time of

publishing.

National CQUINs 2016/17

The national indicators are:

1. NHS staff health and wellbeing;

2. Identification and early treatment of Sepsis;

3. Antimicrobial resistance.

National CQUIN Goals

CQUIN Indicators Goals

NHS staff health and

wellbeing

Goal: Improve the support available to NHS Staff to help promote their health and wellbeing in order for them to remain healthy and well. Rationale: Estimates from Public Health England put the

cost to the NHS of staff absence due to poor health at

£2.4bn a year – around £1 in every £40 of the total budget.

Evidence from the staff survey and elsewhere shows that

improving staff health and wellbeing will lead to higher staff

engagement, better staff retention and better clinical

outcomes for patients.


Identification and

early treatment of

Sepsis

Goal: Systematic screening for Sepsis of appropriate patients and where sepsis is identified, to provide timely and appropriate treatment and review. Rationale: Sepsis is potentially a life threatening condition

and is recognised as a significant cause of mortality and

morbidity in the NHS, with around 32,000 deaths in England

attributed to Sepsis annually. Of these it is estimated that

11,000 could have been prevented.

Antimicrobial

resistance

Goal: Reduction in antibiotic consumption and encouraging focus on antimicrobial stewardship and ensuring antibiotic review within 72 hours Rationale: Reducing consumption of antibiotics and

optimising prescribing practice by reducing the indiscriminate

or inappropriate use of antibiotics which is a key driver in the

spread of antibiotic resistance.

National and Local Indicator Values Depending on provider performance, the CQUIN scheme is worth a maximum of 2.5%, payable in addition to the Actual Annual Value (AAV). The AAV is the aggregate of all payments made to the provider for services

delivered under the specific contract during the contract year, not including CQUIN

and other incentive payments, and after any deductions or withholdings), subject to

certain exclusions.

National Indicator

% of CQUIN quantum

Financial Value

NHS staff health and wellbeing 0.75 £1,199,865

Identification and early treatment

of Sepsis

0.25

£399,950

Antimicrobial resistance 0.25 £399,950


12.0 Care Quality Commission (CQC) Registration Kingston Hospital NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is approved. Kingston Hospital NHS Foundation Trust has the following conditions on registration - none. The Care Quality Commission has not taken enforcement action against Kingston Hospital NHS Foundation Trust during 2015/16. The Care Quality Commission (CQC) is the independent regulator of health and social care in England. It regulates care provided by the NHS, local authorities, private companies and voluntary organisations that provide regulated activities under the Health and Social Care Act 2008. The CQC registers, and therefore licenses, all NHS trusts. It monitors Trusts to make sure they continue to meet very high standards of quality and safety. If services drop below the CQC’s essential standards then it can impose fines, issue public warnings, or launch investigations. In extreme cases it has the power to close services down. Kingston Hospital NHS Foundation Trust is registered with the CQC - every hospital has to be. This means that we are doing everything we should to keep patients safe and to provide good care. The CQC carries out regular checks to make sure that hospitals are meeting important government standards. There are currently no conditions attached to the registration and there has been no enforcement action during the reporting period. The CQC undertake announced and unannounced compliance visits to assess if the service is safe, effective, caring, is responsive to people’s needs and is well-led. During 2015-16 the CQC has been undertaking new style announced compliance inspection visits. The Trust was subject to a new style announced visit in January 2016.

In order to maintain registration as a healthcare provider, the Trust is required to

demonstrate that it is meeting standards across five domains set out by the CQC:

Safe

Effective

Caring

Responsive

Well led

During 2015-2016, the Trust undertook self-assessments of compliance with CQC standards

to monitor the safety and quality of services. CQC compliance is considered at the Board to

provide assurance.

The Trust was inspected by the CQC on the 12 to 14 January 2016. The Trust is awaiting

receipt of the report.

The Trust has not participated in any special reviews or investigations by the CQC during the reporting period. The Trust did receive two outlier alerts from the CQC: June 2015: Maternity Outlier Alert for Perinatal Mortality


• In response to the alert an analysis of case notes was done as well as the review by the maternity risk team and has not identified one clear cause of the raised perinatal mortality rate. Areas for improvement have been identified and these are being monitored via specific action plans. The response and the actions plans were accepted by the CQC. The maternity sign up to safety project features a number of these actions, see page 49.

September 2015 Mortality outlier alert for ‘Septicaemia (except in labour)’

In response to the alert there was a review of case notes. The Trust is taking a number of

actions around sepsis as outlined in our sign up to safety plan and Quality Priorities. The

response and the actions plans were accepted by the CQC. The actions undertaken are

shown in page 29/30 and are part of the actions taken for Priority 1 - Improved recognition

and management of sepsis .

13. Data Quality

The Trust has a five year Data Quality Strategy, of which 2015/16 was the fifth year. The

strategy has a three themed approach to improving data quality in the Trust:

People

Reporting

Systems

The Trust will be consulting on, and subsequently publishing, both a refreshed 3 year

Information Strategy and 5 year Data Quality Strategy during the first quarter of 2016/17.

This will incorporate the recommendations from various national reports, ‘Operational

productivity and performance in English NHS acute hospitals: Unwarranted variations’ [Lord

Carter, February 2016] and the ‘Report of the Mid Staffordshire NHS Foundation Trust

Public Inquiry’ [Robert Francis QC, February 2013], in respect of data quality and the use of

information across services and the wider health economy.

The Trust also subscribes to the external CHKS benchmarking tool, which includes a data

quality measurement component. Kingston Hospital NHS Foundation Trust was once again

a winner of the CHKS Top Hospitals award in 2015. This award recognises the best

performing CHKS client trusts across the UK and is based on the evaluation of 22 indicators

of clinical effectiveness, health outcomes, efficiency, patient experience and quality of care.

Progress against Strategy – 2015/16

During 2015/16 there was a continual progression of actions undertaken towards improving

data quality. One of these key developments was the creation and implementation of service

and function specific data quality dashboards to support information assurance, primarily

focussing on referral to treatment 18 weeks and Accident & Emergency. A further significant

in-house development was an inpatient patient tracker list (iPTL), to support the identification

of delays in patient pathways and those patients who are clinically optimised but remain in

an acute facility (delayed transfers of care).


14.1 Data Quality – NHS Number and General Medical Practice

Code Validity

Kingston Hospital NHS Foundation Trust submitted records during 2015/16 to the Secondary

Uses service for inclusion in the Hospital Episode Statistics which are included in the latest

published data. The percentage of records in the published data which included the patient’s

valid NHS number and General Medical Practice Code was:

KHT 2015/16

(Apr-Jan)

National

2015/16

(Apr-Jan)

% with Valid NHS number 99.4% 99.2%

% with General Medical

Practice Code100% 99.9%



Practice Code99.9% 99.8%






Practice Code99.8% 99.6%




Data source: HSCIC SUS Dashboards

Maternity - Deliveries

DQ Indicator

Admitted Patient Care

Out Patient Care

Accident & Emergency

Care

Maternity - Births

We will be taking the following actions to improve data quality:

There is a data quality group to ensure performance meets and/or exceeds national

performance.


14. Clinical Coding

Clinical coding is the translation of medical terminology written by clinicians and health care

professionals on patient conditions, complaints or reason for seeking medical attention, into

a nationally and internationally recognised coded format. During the process of coding all

clinical coders follow national standards, rules and conventions, in order to achieve accurate,

reliable and comparable data across time and sources.

Kingston Hospital NHS Foundation Trust was not subject to the Payment by Results clinical

coding audit during 2015/16.

As part of the internal clinical coding audit programme, and to comply with the Information

Governance Toolkit Standard 13-505, an audit has been undertaken by qualified and

accredited members of the Clinical Coding team across 200 Finished Consultant Episodes

during 2015/16. The error rates reported for that period for diagnoses and procedure coding

(clinical coding) were:

KHT 2015/16

Total number of episodes examined:

* 130 episodes in General Medicine

* 70 episodes in General Surgery

200

Primary Diagnoses Incorrect 2.5%

Secondary Diagnoses Incorrect 2.2%

Primary Procedures Incorrect 2.6%

Secondary Procedures Incorrect 1.1%

Data source: KHFT IG Audit, March 2016

It is important to note that:

The results should not be extrapolated further than the actual sample audited and;

The services reviewed within the sample were General Medicine (130 records) and

General Surgery (70 records).


15. Information Governance Toolkit Attainment Levels

The Trust’s Information Governance IG Toolkit Assessment Report overall score for 2015/16

was 80% (2014/15 was 81%; Green-Satisfactory) and was graded Green – Satisfactory

across all Six Assurances.

The 2015/16 result is from version 13 of the Toolkit. As in previous years the evidence has

been rolled over from previous versions to which we have added any new or revised policies

and in-year evidence to support monitoring and compliance.

The Requirements have changed between versions. There are currently 45 requirements

for Acute Trusts. The results by Assurance Level were as follows:

Assurance 2015/16 V13 2014/15 V12

Information Governance Management 80% 80%

Confidentiality and Data Protection Assurance 74% 81%

Information Security Assurance 75% 73%

Clinical Information Assurance 86% 80%

Secondary Use Assurance 95% 100%

Corporate Information Assurance 77% 77%

Overall Total 80% 81%


16. National Data from the Health and Social Care Information Centre (HSCIC)

The tables below represent Kingston Hospital's performance across a range of indicators (as published on the Information Centre Website www.hscic.gov.uk). Many of these are also reported monthly at the public Trust Board meeting as part of the Clinical Quality Report. The data shown is correct as at March 2016.

Indicator Trust National Minimum Maximum Comment

Summary Hospital-

level Mortality

Indicator (SHMI)

Oct 2013 – Sep

2014

0.8728 1 0.5966 1.1982

Lower is

better.

We are

below the

national

average.

Summary Hospital-

level Mortality

Indicator (SHMI) Oct

2014 –Sep 2015

0.9318 1 0.6516 0.986080271 Lower is

better.

We are

below the

national

average.

Latest Data

Published

March 2016

The Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons – high level of clinical coding accuracy. The Kingston Hospital NHS Foundation Trust has taken the following action to improve this indicator and the quality of its services - enhanced medical leadership at Service Line level.



Percentage of deaths

with palliative care

coded

Oct 2013 – Sep 2014

26.9984 25.6840 0 50.8513 We are above

the national

average.

Higher number

is better.

Percentage of

deaths with palliative

care coded

Oct 2014 –Sep 2015

25.5796 26.5867 0.1898 52.9080 We are below

the national

average.

Higher number

is better.

Latest Data Published March 2016

The Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons - high level of clinical coding accuracy. The Kingston Hospital NHS Foundation Trust has taken the following action to improve this percentage and so the quality of its services – provision of a well embedded palliative care specialist support team and training and guidance for staff.


Age <16 readmissions within 28 days 2010/11

8.30% 10.45% 0.00% 16.05% We are below the national average. Lower number is better.

Age <16 readmissions within 28 days 2011/12

9.45% 10.03% 0.00% 14.94% We are below the national average. Lower number is better.

Latest Data Published December 2013

Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons - high level of data coding accuracy.

Kingston Hospital NHS Foundation Trust has taken the following action to improve this rate, and so the quality of its services – by working in partnership with our community colleagues.



Age 16+ readmissions within 28 days 2010/11

12.01% 11.43% 0.00% 41.65% We are below the national average. Lower number

is better.

Age 16+ readmissions within 28 days 2011/12

11.06% 11.45% 0.00% 22.76% We are below the national average. Lower number

is better.

Latest Data Published December 2013

Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons - high level of data coding accuracy. Kingston Hospital NHS Foundation Trust has taken the following action to improve this rate, and so the quality of its services – by working in partnership with our community colleagues.


Trusts responsiveness to the personal needs of its patients April 2013 – March

2014

64.1 68.7

54.4 84.2

We are below national average. Higher number is better.

Trust’s responsiveness to the personal needs of its patients April 2014 – March 2015

64.9 68.9

59.1 86.1

We are below national average. Higher number is better.

Latest Data Published

Aug 2015

Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons - high level of data accuracy. Kingston Hospital NHS Foundation Trust has taken the following action to improve this rate, and so the quality of its services - by delivering the inpatient action plan. By delivering the quality account priorities and corporate objectives.



Staff who would recommend Trust as a provider to friends and family Staff Survey 2014

60 65 0 93 We are below national average. Higher number is better.

Staff who would recommend Trust as a provider to friends and family Staff Survey 2015

68 68 0 100 We are equal to the national average. Higher number is better.


March 2015

Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons - high level of data accuracy. Kingston Hospital NHS Foundation Trust has taken the following action to improve this rate, and so the quality of its services: By delivering the quality account priorities and corporate objectives. By improving staff engagement and delivering our workforce strategy including the implementation of the positivity programme.


% of patients admitted that were risk assessed for

VTE Apr 2015 – Jun 2015

98.50% 96.00% 86.10% 100.00%

KHT above national average. Higher number is better.

% of patients admitted that were risk assessed for

VTE Jul 2015 – Sep 2015

98.60% 95.90% 75.00% 100%

KHT above national average. Higher number is better.


December 2015

Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons - high level of data coding accuracy. Kingston Hospital NHS Foundation Trust has taken the following action to improve this rate, and so the quality of its services – by enhancing our computer system to make VTE assessment a mandatory field and raising awareness in staff.



Rate per 100,000 bed days for C.diff reported within the Trust for patients >2 years old

April 2013 – March

2014

15.8 14.7 0.0 37.1

KHT above national average. Lower number is better.

Rate per 100,000 bed days for C.diff reported within the Trust for patients >2 years old

April 2014 – March

2015

12.2 15.1 0.0 62.2

KHT below national average. Lower number is better.


July 2015

Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons – sustained focus across the organisation and close monitoring of results. Kingston Hospital NHS Foundation Trust has taken the following action to improve this rate and so the quality of its services - by delivering its infection control action plan.


Number and % of patient safety incidents Apr 2014 – Sep 2014

Number 2,303 35 12,020 There is no national average .

Rate per 1,000 bed days 33.8 0.2 196.30

Number and % of patient safety incidents October 2014 – March 2015

Number 2,292 300 12,784 There is no national average

Rate per 1,000 bed days

31.8 3.6 170.8

Latest Data Published November 2015

Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons – derived from our own data collection procedures. Kingston Hospital NHS Foundation Trust has taken the following action to improve this rate, and so the quality of its services – by promoting to staff the importance of completing incident reports and providing incident reporting training.



Number and % of patient safety incidents that result in severe harm or death October 2013 – March 2014

Number 11 0.0 97

There is no national average Lower number

is better

Rate per

1,000 bed

days 0.16 0.0 3.03

Number and % of patient safety incidents that result in severe harm or death October 2014 – March 2015

Number 14 0 128

There is no national average Lower number

is better

Rate per

1,000 bed

days 0.19 0.0 0.0

Latest Data Published November 2015

Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons – derived from our own data collection procedures. Kingston Hospital NHS Foundation Trust has taken the following action to improve this rate, and so the quality of its services – by promoting to staff the importance of completing incident reports and providing incident reporting training.

Indicator Trust1 National Minimum Maximum Comment

Patient Reported Outcome Measures (PROMS) Groin Hernia April-15 –September-15

Participation rates for the first questionnaire

- 56.4% 0.0% 442.9%

Response rates for the second questionnaire

- 43.0% 0.0% 100.0%

Health Gain (EQ-5D)

- 49.4% 0.0 0.1

Health Gain (EQ-VAS)

- 36.7% -7.5 3.1

Latest Data Published February 2016 1 Indicates the figure has been suppressed (shown with an asterisk - '*') to protect patient confidentiality as published by HSCIC. The Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons - data derived from returns to national data collection procedures.


Kingston Hospital NHS Foundation Trust is taking the following action to improve this rate, and so the quality of its services: Implement an action plan to ensure PROMS returns are made.


Patient Reported Outcome Measures (PROMS) Varicose Vein surgery April-15 –September-15

Participation rates for the first questionnaire

- 31.6% 0.0% 214.3%

Participation rates for the second questionnaire

- 29.0% 0.0% 87.5%

Health Gain (EQ-5D)

- 52.0% 0.0 0.1

Health Gain (EQ-VAS)

- 39.8% -5.1 4.8

Health Gain Aberdeen Score

- * -13.3 0

Latest Data Published February 2016

The Kingston Hospital NHS Foundation Trust considers that this data is as described for the following reasons - data derived from returns to national data collection procedures. Kingston Hospital NHS Foundation Trust is taking the following action to improve this rate, and so the quality of its services: Implement an action plan to ensure PROMS returns are made.

Elective knee and hip replacements are done at the South West London Elective Orthopaedics Centre

The Quality Report is prepared each year by the Director of Nursing and Patient Experience and overseen by the Quality Assurance Committee. This group is chaired by a Non – Executive and attended by the Chief Executive. Any guidance issued by the Secretary of State related to the Health Act (2009) is reviewed in the 6 months leading up to the publication of the Quality Report. Such guidance would be appropriately incorporated into the Quality Report prior to finalisation.


17. Independent Auditors’ Limited Assurance Report to the Directors of Kingston Hospital NHS Foundation Trust on the Quality Report

We have been engaged by the Board of Directors and Council of Governors of Kingston Hospital NHS Foundation Trust to perform an independent limited assurance engagement in respect of Kingston Hospital NHS Foundation Trust’s Quality Report for the year ended 31 March 2016 (the ‘Quality Report’) and certain performance indicators contained therein. Scope and subject matter The indicators for the year ended 31 March 2016 subject to limited assurance consist of the national priority indicators as mandated by Monitor:

Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period

Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers

We refer to these national priority indicators collectively as the ‘indicators’. Respective responsibilities of the directors and auditor The directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set out in the ‘NHS Foundation Trust Annual Reporting Manual’ issued by Monitor. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that:

the Quality Report is not prepared in all material respects in line with the criteria set out in the ‘NHS Foundation Trust Annual Reporting Manual’

the Quality Report is not consistent in all material respects with the sources specified in Monitor's 'Detailed guidance for external assurance on quality reports 2015/16, and

the indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with the ‘NHS Foundation Trust Annual Reporting Manual’ and the six dimensions of data quality set out in the ‘Detailed guidance for external assurance on quality reports 2015/16

We read the Quality Report and consider whether it addresses the content requirements of the ‘NHS Foundation Trust Annual Reporting Manual’, and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Report and consider whether it is materially inconsistent with: • Board minutes for the period 1 April 2015 to 19th May 2016 • Papers relating to quality reported to the Board over the period 1 April 2015 to 19th May 2016 • Feedback from Commissioners dated [20/05/16]; • Feedback from Governors dated [19/05/16];


• Feedback from local Healthwatch organisations dated [20/05/16]; • Feedback from Overview and Scrutiny Committee dated [20/05/16];• The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and

NHS Complaints Regulations 2009, dated [14 April 2016] • The national patient survey dated [2015] • The national staff survey dated [22/03/2016] • Care Quality Commission Intelligent Monitoring Report dated [28/05/2015]; and • The Head of Internal Audit’s annual opinion over the Trust’s control environment; and • Any other information obtained during our limited assurance engagement. 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 Board of Directors and Council of Governors of Kingston Hospital NHS Foundation Trust as a body and the Board of Directors of the Trust as a body, to assist the Board of Directors and Council of Governors of Kingston Hospital NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2016, to enable the Board of Directors and 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 Board of Directors as a body, the Council of Governors as a body and Kingston Hospital NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial Information’, issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included:

evaluating the design and implementation of the key processes and controls for managing and reporting the indicators

making enquiries of management

analytical procedures

limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation

comparing the content requirements of the 'NHS Foundation Trust Annual Reporting Manual 2015/16' to the categories reported in the Quality Report; and

reading the documents. A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations


Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different, but acceptable measurement techniques which can result in materially different measurements and can affect comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision of these criteria, may change over time. It is important to read the Quality Report in the context of the criteria set out in the ‘NHS Foundation Trust Annual Reporting Manual’. The scope of our assurance work has not included governance over quality or non-mandated indicators, which have been determined locally by Kingston Hospital NHS Foundation Trust. Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016:

the Quality Report is not prepared in all material respects in line with the criteria set out in the ‘NHS Foundation Trust Annual Reporting Manual’;

the Quality Report is not consistent in all material respects with the sources specified above; and

• the indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with the 'NHS Foundation Trust Annual Reporting Manual 2015/16' and supporting guidance and the six dimensions of data quality set out in the 'Detailed guidance for external assurance on quality reports 2015/16'.

Grant Thornton UK LLP Grant Thornton House, Melton Street, Euston Square, London NW1 2EP

[19/05/16]


Appendix 1: National Confidential Enquiries

Programme type Participated? Study and number of cases submitted

Child Health Clinical Outcome Review Programme

Yes Young People’s Mental Health – taking part, study in early stages Chronic neuro-disability – taking part, study in early stages

Medical and Surgical Clinical Outcome Review Programme

Yes Mental health Study – 5 cases Acute Pancreatitis - 5 cases and organisational questionnaire Sepsis – 4 cases and organisational Questionnaire Gastrointestinal haemorrhage – 5 cases and organisational questionnaire

Maternal, Newborn and Infant Clinical Outcome Review Programme

Yes Perinatal mortality surveillance – 38 cases Maternal mortality surveillance – 0 cases

Mental Health programme Not applicable


Appendix 2: Eligible National Clinical Audits 2015/16 – Participation rates Shaded areas indicate national clinical audits where deadlines are after April 2016 and therefore the number of cases submitted is not yet available.

National Clinical Audit Participated? Number of cases submitted

Acute Care

Case Mix Programme (ICNARC) Yes 77% (558/721)

Trauma Audit and Research Network (TARN)

Yes 38% (104/276)

National Emergency Laparotomy Audit (NELA)

Yes 100%

National Joint Registry – hips/knees Yes 44 cases entered (target unknown)

Non-invasive ventilation Although listed in the 2015/16 Quality Accounts, this audit has not taken place this year

Emergency use of oxygen Yes 410% (41 cases submitted/10 minimum requirement)

Procedural sedation in adults Yes 78% (39/50)

Vital signs in children Yes 200% (100 cases submitted /50 minimum required)

VTE risk in lower limb immobilisation Yes 200% (100 cases submitted /50 minimum required)

National complicated diverticulitis No No indication was received that this audit had started

Blood transfusion

National Comparative Audit of Blood Transfusion audits: Use of blood in haematology Patient blood management in scheduled surgery

Yes Yes

100% (40 cases) 100% (31 cases)

Cancer Bowel Cancer (NBOCAP) Yes 117% (160/137)

Lung Cancer (NLCA) Yes 100% (102 cases submitted/all eligible cases n=102)

National Prostate Cancer Audit Yes 99% (174/176)

Oesophago-gastric Cancer (NAOGC) Yes 124% (48 cases)

Heart Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP)

Yes 100% (172/172)

Cardiac Rhythm Management Yes 100% (122/122)

Coronary Angioplasty/National Audit of PCI

Yes 1/1 (100%) organisational audit.

National Cardiac Arrest Audit Yes 49% (96/195)

National Heart Failure Audit Yes 49% (130/263) – still entering data

Long Term Conditions

National Diabetes Audit (Adult): Footcare In-patient Pregnancy in diabetes

No

Yes

No

Data has been collected but not yet submitted 44 cases submitted plus 34 /44 completed patient forms Requirement for patient consent for audit meant no data entered


National core

Yes

2015/16. Audit started March 2016. 83 cases – percentage not known

National Diabetes Audit (Paediatric) Yes 100% (144/144) cases submitted

Inflammatory Bowel Disease (IBD) Yes 100% (70/70)

National Chronic Obstructive Pulmonary Disease (COPD): Secondary care

Yes

Data entered in 2014 (no data collection in 2015/16)

Rheumatoid and Early Inflammatory Arthritis

Yes 35 cases – percentage not known

Older People

Falls and Fragility Fractures Audit Programme (FFAP): Fracture Liaison Service database In-patient falls National Hip Fracture Database

Yes

Yes Yes

Facilities part of audit – organisation questionnaire only 100% (30 cases) 92% (287/312) – still collecting data

Sentinel Stroke National Audit Programme (SSNAP) Clinical Audit

Yes 100% (163/163) – Continuous audit, still submitting data.

UK Parkinson’s Audit Yes Organisational audit completed 100% (25 cases)

Other

PROMS – Hernia and varicose veins only No information yet received

National Ophthalmology Audit No Awaiting funding for IT system to allow participation

Women and Children

Neonatal intensive and special care (NNAP)

Yes 100% (392 cases)

Paediatric Asthma Yes 200% (40 cases submitted / 20 minimum required)

Paediatric Pneumonia Although listed in the

2015/16 Quality

Accounts, this audit has not taken place

this year


Appendix 3: Actions to be taken following completed national clinical audits

National audit reports published in 2015/16

Date Report Issued

Report discussed during 2015/16

Actions Identified

Acute Care

Emergency use of oxygen Dec 2015 Yes Oxygen awareness week taking place in Kingston Hospital during Spring 2016

Adult critical care case mix programme (ICNARC)

Jan 2016 Yes Data currently being reviewed in order to formulate action plan

Major Trauma Audit (TARN)

Nov 2015 Yes Results circulated to A&E team.

National Emergency Laparotomy Audit

Oct 2015 Yes Extensive action plan including appointment of new Emergency Surgeons and Consultant in Medicine for older people, direct post- operative admission to ITU and various policies and guidelines. Major improvement in patient care has been identified as a result of these actions.

National Joint Registry Sept 2015 Yes No Kingston Hospital data in this report, therefore no action plan required.

Blood transfusion

Blood management in scheduled surgery

Oct 2015 Yes A specific anaemia clinic is being considered.

Cancer

Bowel cancer Dec 2015 Yes Results good, no actions required

Lung cancer Dec 2015 Awaiting presentation in

Respiratory

Action plan to be devised after discussion, if required

Prostate cancer Nov 2015 Yes No Kingston Hospital data in this annual report, since data entry did not begin until October 2014. Therefore no actions required at this stage.

Oesophago-gastric cancer Dec 2015 Awaiting presentation in

Gastroenterology

Results good. Actions may not be required.

Heart

National cardiac arrest audit

Jul 15

Yes Actions include ensuring staff complete cardiac arrest forms, reviewing location of cardiac arrests and presenting data to clinicians.


National Heart Failure audit

Oct 2015 (1314 data)

Yes Cardiology Audit Assistant and Heart Failure Nurse Specialists appointed

Long term conditions

Inflammatory bowel disease Biologics audit

Sep 2015

Yes New IBD Nurse Specialist appointed

Yes Results have been circulated

to Diabetes team

Yes Results have been circulated to Diabetes team

Yes Results have been circulated

to Diabetes team

Yes Results have been circulated to Diabetes team

Yes Actions to be taken link with the action plan

for NICE Quality

Standard 33, including review of patient

pathway.

Yes Actions to be taken link with the action plan for NICE Quality Standard 33, including review of patient pathway.

Mental Health

Mental health in the ED May 2015 Yes Addition of a risk assessment tool as part of triage and ensure that psychiatric liaison notes are incorporated into the electronic patient record

Older People

Sentinel stroke national audit programme

Dec 2015 (annual) Feb 16

(organisational)

Yes Results good, no actions required.

Falls and fragility fracture programme In-patient falls National Hip Fracture database

Assessing for cognitive impairment in older people

May 2015 Yes Prepare specific dementia screening guideline for use in A&E. Review content of electronic patient record for this group of patients.

Women and Children

Neonatal intensive and special care

Nov 2015 Yes Actions including improving compliance with breast feeding initiatives and improving documentation

Management of the fitting child

May 2015 Yes Training update for staff regarding blood test requirements, modify local guideline, consider simulation teaching session,


and ensure patient/parent information is available in A&E.

National audit reports published in 2015/16

Acute Care

Emergency use of oxygen Dec 2015 Yes Oxygen awareness week taking place in Kingston Hospital during Spring 2016

Adult critical care case mix programme (ICNARC)

Jan 2016 Yes Data currently being reviewed in order to formulate action plan

ANNEX 1 – Containing Regulation 5 Statements The Trust is grateful for the feedback received from our commissioners and other stakeholders, and looks forward to working closely with them in the coming year to improve the services we provide to the people of Kingston. Where we have received direct comments back from patient representatives (outside of the formal response from stakeholders) we have endeavoured to include these in the final version of the Quality Report.

Kingston Hospital NHS Foundation Trust – Commissioner Feedback The Kingston Clinical Commissioning Group (CCG) welcomes the opportunity to provide a

response to the Quality Account for 2015/16 submitted by Kingston Hospital NHS Foundation Trust.

The Quality Account provides information and a review of the performance of the Trust against

quality improvement priorities set for the year 2015/16 and gives an overview of the quality of care

provided by the Trust during this period. The priorities for quality improvement for the next 12

months are also set out which we were consulted upon and endorse.

The CCG supports the Trust’s openness and transparency. We are committed to working with the

Trust to achieve further improvements and successes in the areas identified within the Quality

Account. This will be carried out through a number of both proactive and reactive mechanisms and

collaborative and integrated working.

The challenging targets set by the Trust for 2015/16 were fully met for 5 of the 9 priorities and

partially met in the remaining 4 areas.

The improved recognition and management of sepsis shows the positive steps the Trust has taken

to improve performance in this patient safety area and we look forward to the sustained focus as

part of the Trusts commitment to the “Sign up to Safety” campaign.

The significant progress made in reducing agency usage (in particular, the recruitment and training

of staff to support reductions in turnover) is commendable in the current workforce climate.

The use of technology to release nursing time and improve the recording of patients vital signs is

very innovative and we would welcome the planned expansion of the coverage in the Trust (as


funding allows).

Section 6 highlights other areas of improvement across the Trust in addition to the quality account

priorities and the membership of the Clinical Quality Review Group (CQRG) in particular would wish

to recognise the improvements seen in pressure ulcer prevention and the sustained improvement to

food quality and support for patients at mealtimes.

Most notably, the performance achievements for cancer patients has seen the Trust move from a

challenged and variable level of cancer target achievement to a position of high confidence in the

pathways for patients. The performance over the last quarter and year end place it amongst the top

performing Trusts in London and is to be commended.

Similar to the wider NHS, the Trust will need to continue its focus on emergency access (through

Accident and Emergency) and build upon the programmes of partnership working already in place

with Health and Social Care colleagues to support patients leaving the Trust to avoid any possible

delays.

The CCG is supportive of the engagement model used with Commissioners, Governors and

Healthwatch in the development of the quality priorities for 2016/2017 and wholly supports the

goals and the improvements that the Trust plans to undertake over the next year.

The CCG looks forward to continuing to work with the Trust during the coming year, to build on the

progress made and to provide support to initiatives that will improve the quality of care and

outcomes.

Trust Response

We thank Kingston Clinical Commissioning Group for their constructive feedback. The Trust values

the level of engagement from the CCG and looks forward to continuing the collaborative work being

done to provide patients with the best care. The Trust and local partners are already working

closely to avoid delayed transfers of care and ensure a safe and timely discharge for patients. The

Trust intends to build on work during 2016-17 to improve the patients experience of discharge.

Kingston Hospital NHS Foundation Trust – Governor Feedback

The Governors have reviewed the Trust's Quality Report for 2015/2016 and acknowledge that the

Trust demonstrates commitment to continuously improving the care it provides. The Governors

welcomed the opportunity to engage with the Trust in agreeing priorities. The Trust was open to

suggestions, comments and feedback on all aspects of the Quality Report and the priorities. In

particular the governors felt that it is important the priorities have clear outcomes for patients and

carers, are measurable and easy to understand by the public.

The Trust partly met 4 priorities last year and fully met the other 5 priorities. It is welcomed that the

Trust will continue to take forward ongoing priorities in reducing vacancies, sepsis, discharge,

administration and end of life care as well as new priorities on falls, pain, readmission and length of

stay. These priorities represent areas that have a direct impact on how patients experience care.

The Governors' Quality Scrutiny Committee was able to give assurance to the Council of Governors

(COG) that the Quality Account process was rigorous and inclusive, engaging a wide range of


stakeholders. The governors are looking forward to working with the hospital to ensure this year’s

priorities are a success in providing safe and effective care for patients.

Trust response The Trust is grateful for the feedback received from the Council of Governors and looks forward to working closely with the Governors in the coming year to improve the services we provide to patients. The Trust acknowledges that the feedback from the Governors throughout the development of the Quality Account was valuable in making the priorities clearer and easier to understand.

Re: Quality Account 2015/16

Healthwatch Kingston welcomes the opportunity to comment on the 2015/6 Quality Account, a comprehensive document that describes another year of progress and a range of improved outcomes. Healthwatch has been able to visit the hospital on a number of occasions in the past year through the 'enter and view' process to see for ourselves how services are delivered and operated, enabling our members to see tangibly what the detailed account describes. The principal monitoring exercise was the CQC inspection in January 2016 and we await with anticipation the Inspection Report, whilst noting the outlier alerts relating to perinatal mortality and sepsis. Measures to address these concerns have been developed and we look forward to being able to assess progress throughout 2016/7. The account focuses on the key themes of safe, effective, caring, responsive and well led, and so Healthwatch will for the year ahead aim to consider how to reflect these themes in our own visits, just as the CQC and Monitor have for themselves in recent inspections. Some specific highlights we welcome include:

the progress made in reducing cancer waiting times good progress in the development of 7 day working in key areas such as paediatrics,

medicine and surgery the general exceeding of clinical coding requirements higher recommendation rates to friends and family introduction of vital signs monitoring

The recent appointment of new permanent Chief Executive is welcomed and Healthwatch will look forward to meeting her and her senior team shortly. Clearly the Quality Account is a substantial document with significant scope and much detail, produced in response to external reporting requirements. As the health service user and consumer focussed body for Kingston where a significant number of Kingston Hospital patients live, we will continue to scrutinise this and other reports to get to the heart of what is happening, celebrate what is going well and identify where practice could be improved. The Hospital's open and constructive approach to enabling us to carry out our work remains a very welcome feature of our strong relationship.


The Trust Response The Trust is grateful for the feedback received from Kingston Healthwatch. We would like to recognise the valuable feedback from Kingston Healthwatch in developing and selecting the Quality priorities. We believe the work we do with our local Healthwatch groups is very important to providing safe and effective care for patients. We look forward to continuing to work with Kingston Healthwatch

Royal Borough of Kingston upon Thames

Kingston Hospital Foundation Trust Quality Account (2015/16) – Comments from Kingston

Council’s Health Overview Panel

This year’s report provides detailed information about progress made in the past year. It clearly

sets out what the Quality priorities set out to achieve and progress against these.

As well as reporting against the nine Quality Priorities agreed for 2015/16 it considers the themes

which are examined both by Monitor and the Care Quality Commission in inspections. Evidence is

therefore provided to demonstrate effective progress and outcomes against the following themes:

Safe, Effective, Caring, Responsive and Well-led

We particularly commend the progress made in 2015/16 to improve the provision of 7 day working

for paediatrics, surgery and medicine and in reducing the use of agency staff. We are pleased to

see that further work on these two priorities will continue into next year. Progress on discharge

planning is also commended. However, The Trust’s performance in the national inpatient falls audit

is a concern with the Trust being rated as red against five of the recommendations and amber

against the other two. We very much agree that reducing falls in the hospital setting should be a

priority for 2016/17 and look forward to progress being made by the Trust in their performance

against these priorities. We also note that not all the targets set for ‘Improved recognition and

management of sepsis’ were achieved and also look forward to progress being made in 2016/17.

We also note the new priorities of reducing length of stay and reducing re-admissions for people

who have required emergency care (non-elective care). These (together with a wide range of other

actions by the Trust and key partners) will assist in achieving a sustainable local health service in

future years.

We note the strong participation in national clinical audit programmes. We also recognise the

progress made in cancer waiting times in the past year and hope that this can be sustained and

further progress made in 2016/17.

We also note that the Trust did receive CQC outlier alerts for perinatal mortality and sepsis. We

recommend that perinatal mortality continues to be reviewed by clinical audit in 2016/17 and we

endorse the continuing focus on sepsis as part of the nine quality priorities for the coming year. We

were pleased to see the introduction of healthcare technology for vital signs monitoring when we

visited A&E and other areas in December 2015 and note the Trust’s success at attracting funding

for this.

We look forward to seeing the CQC Inspection Report (of the planned visit in January 2016) in due

course.

We are pleased to note that for all data quality indicators the Trust performed better than the

national average. We hope further progress can be made on capturing palliative care coding for


deaths (and wish to point out that for October 2014 to September 2015 (page 72) the Trust

performed below the national average but the comment incorrectly states it performed above) –

which will link with the 2016/17 Priority Action to improve end of life care. We note the recent

publication of CQC review of palliative care which details exemplar sites of good practice.

We were also pleased to see the progress on the indicator concerning staff who would recommend

Trust as a provider to friends and family. KHFT now equals the national average and we hope that

further progress can be made.

We are particularly pleased to learn of the permanent appointment of Ann Radmore as Chief

Executive in May 2016 and believe this will be of great benefit to the Trust going forward.

Trust Response The Trust is grateful for the constructive feedback received from Kingston Council Health and Overview panel. We have made the correction to the quality indicator on palliative care coding. Our Sign up to Safety Programme will focus on sepsis and maternity. We will continue to work in partnership with Kingston Council to provide the best care for local people.

Commentary on Kingston Hospital NHS Foundation Trust Quality Accounts 2015-2016

Healthwatch Richmond considers the Trust's Quality Account (QA) for 2015/16 to be an accurate reflection of Kingston Hospital's achievements. Although the report is lengthy, it covers a good range of topics, all interesting and relevant. The QA is well laid out and easy to read, and the definitions of the unavoidable technical or medical terms are helpful. The use of tables with clear explanations is accommodating to the reader. The QA gives an encouraging picture of ongoing improvements and clearly details the areas where there is continued room for improvement. As a consequence, an encouraging picture of the hospital's excellent work emerges.

Considerable effort appears to have gone into nurse recruitment and commensurate reduction in the use of agency nurses. This is a priority the Trust has pledged to continue, in order to further improve services and achieve the London Quality Standards, including the delivery of 7-day services. We particularly welcome the on-going commitment by the Trust to ensure a consultant is available for ward reviews 7 days a week, and increase the numbers of pharmacists and therapists working at the weekends.

This action will allow a 7 day a week multi disciplinary review of patients. The local population will be reassured to learn of the recruitment drive and enhanced consultant cover, which will permit 24/7 access to a consultant in specialities such as paediatrics, obstetrics and emergency surgery. The Trust indicates that the full effect of these changes will be realised in 2016/17. We look forward to seeing evidence of improvements in patient service.

Healthwatch Richmond is impressed with the Trust's approach and the progress in increasing patient involvement, engaging volunteers and the wider stakeholder community, including Healthwatch. The Trust recognises the valuable role volunteers can play, and demonstrates this with initiatives such as Dining Champions and Dementia Volunteers. It is encouraging to read that volunteers have improved the mood and wellbeing of patients with dementia by 42%. With a high

proportion of Kingston residents over the age of 65 years, this will provide reassurance.

The Trust has been candid in admitting failures to meet some targets and has provided clear reasons why this occurred and what action is being taken to continue improvement. Some of the CQUIN scores were well below 100%; this could have been explained in more depth.


The inclusion of statements of assurance about audits, information management and data quality is helpful. In each priority area, there is evidence of clear internal arrangements for managing and delivering the planned improvements with identified lead roles. The addition of information on how and why priorities were chosen is useful and further demonstrates the Trust’s commitment to inclusion.

There appears to be some way to go in achieving the targets for prevention of sepsis over a 3-year period. This is concerning, given that this is a treatable condition if recognised promptly. We welcome the inclusion of this as a priority for 2016/17 and note the range of improvement measures being put in place by the Trust.

Similarly, the Trust has been open about partly achieving the target to identify and monitor harm to patients with dementia, as the monitoring systems were not put in place until August. Nevertheless there appears to be a system for recording incidents to identify dementia and track specific harms.

Monitoring of data shows that patient falls is a significant issue. We welcome the inclusion of reducing patient falls as a priority for 2016/17.

The Trust has achieved three targets in relation to the working conditions for staff. Significant for patients is the use of electronic recording of vital signs, freeing staff to spend more time with patients. This will also be a priority for 2016/17, as systems are rolled-out to A and E and other areas, subject to funding.

The Trust has performed better than planned in the area of staff appraisal and mandatory training. This is to be welcomed, given the implications for improved care. It is perhaps disappointing that this is not a priority next year, but the Trust has a corporate objective to improve staff experience during 2016/17.

It is concerning that the Trust has only partly achieved targets around improving patient experience. However, the new telephone system has helped improve the response to calls and this is welcome.

There seem to be no hard data about complaints, but the Trust says there is a trend to reduction over the year. We are pleased this is a priority for 2016/17.

There is evidence of achieving the target relating to improving end of life care for patients and their relatives, using an external survey technique. In some cases (care from doctors and nurses), the Trust has performed better than national averages. It is reassuring that this area remains a priority for next year and that the Trust has an action plan in place.

We are pleased the Trust has achieved the target for improving discharge planning and processes. Some more detailed figures would be welcome, but the tracking and reporting systems now in place should facilitate close management. It is pleasing that this is again a priority for next year.

Healthwatch Richmond welcomes the Trust’s pledge in its Patient Public Involvement Strategy to reach marginalised and hard to reach groups, in order to improve outcomes for the public.

Overall we think the Trust has achieved much over the past year, with a number of key areas being taken forward for further action, accompanied by a commitment to improving quality and patient outcomes in 2016/17.

Trust Response

The Trust would like to recognise that the valuable feedback from Richmond Healthwatch in developing and selecting the Quality priorities. We look forward to continuing to work with Richmond Healthwatch making sure we provide the best possible services to the local community. We welcome the comments on the CQUINS and will provide additional explanations in future years on performance. The Trust would like to note there is data on complaints in the report and a table of


the type of complaints regarding administration and we will consider how to make the information clearer in future years.

Richmond upon Thames’ Health Scrutiny Committee response to Kingston Hospital NHS Foundation Trust’s Quality Accounts

Following on from the meeting held on Thursday 19th May 2016, to discuss Kingston Hospital NHS Foundation Trust Quality Account, we welcome the opportunity to provide additional input, as the London Borough of Richmond upon Thames (hereinafter ‘LBRuT’) is committed to champion the interests of its residents by playing a full and a positive role in ensuring that the people living and working in LBRuT have access to the best possible healthcare and enjoy the best possible health. Whilst we appreciate that the version provided is a draft and the final version is yet to be approved we have a number of points we wish to raise and a number of suggestions we wish to proffer. We would like to take this opportunity to commend the Trust on a well laid-out and easy to read report. We were pleased to hear that considerable progress has been made in many quality areas over the past year. The LBRuT particularly noted the Trust’s accomplishments in the following areas during 2015/16:

created additional capacity and featured highly in patient satisfaction feedback;

perience, achieved through initiatives such as improvements in administration; a new 24/7 outreach team supporting very sick patients on the wards, and a new paper light system to release clinical time for patient care;

a Strategy, with Dementia Champions in place across the hospital and the opening of the first dementia friendly ward in November 2017;

taking place, such as increased consultant cover; a focus on patient safety, including a paediatric consultant on site until 10.00PM every night; an increase in consultant obstetric hours; and an increase in the number of emergency surgeons cover by 3. We also welcome the extension of the palliative care service from 6 days to 7;

Survey measures which were better than the national average;

focus on the health and wellbeing of staff and patients, as demonstrated by the implementation of the national staff health and wellbeing CQUIN, and the complete ban on smoking on-site. Suggestions: We have a number of points we wish to raise and a number of suggestions we wish to see incorporated in the final version, as we believe that these will further highlight the hard work and commitment which has taken place to improve the level of quality at Kingston hospital.

challenge of working across 5 boroughs, with 5 different systems and processes, and the recent problems with social care response which is being addressed as a priority by the Council. We welcome that a new single process to improve discharge is being developed and that there is much closer working between agencies on this issue;


ndicator and recognise the benefits, in terms of cost reduction and improved patient care, of better rates of recruitment and retention. It might be useful to include the incentives you are offering to staff for better retention;

eference the Outcomes Based Commissioning (OBC) approach in the Quality Accounts. We were pleased to hear that the OBC process was resulting in greater partnership working across primary care, community services and hospitals that service Richmond residents. It is also a key Health & Wellbeing Board priority to promote a more integrated patient experience;

national health and wellbeing CQUIN for staff, but would also like the trust to focus on self-care and self-management in line with Richmond’s Council and Richmond CCG’s Prevention Framework, Better Care Fund and Better Care Closer to Home Strategy.

welcomed that this is recognised by the Trust and measures to improve this will be undertaken in municipal year 2016/17;

particularly those results reported by staff from minority ethnic groups who were less satisfied with the Trust than other staff. The panel further suggested to encourage patients and carers, such as older people/ people with dementia, those at the end of life and ‘seldom heard groups’ to participate in the patient satisfaction survey;

e hospital setting – Council is pleased to see this as a priority for 2016/2017 and would be keen to hear any feedback on how this reduction is achieved;

– In winter 2014, the Trust reported increased incidence of sepsis. It would be useful to know what learning the Trust has taken from this, to help achieve this priority. Conclusion Our aim is to ensure that your Quality Account reflects the local priorities and concerns voiced by our constituents, as our overall concern is for the best outcomes for our residents. Overall, we are happy with the QA, agree with your priorities and feel that it meets the objectives of a QA – to review performance over the previous year, identify areas for improvement, and publish that information, along with a commitment about how those improvements will be made and monitored over the next year. We hope that our views and the suggestions offered are taken on board and acted upon. We wish to be kept informed of your progress throughout and thereafter. Trust Reponses The Trust is grateful for the constructive feedback received from Richmond Council Health and Overview panel. We have now indicated that the sepsis priority contains the actions we have taken in response to the CQC alert. As a result of feedback from Richmond Council Health and Overview Panel we have included in the report the work we have done to make the hospital site smoke free and reaffirmed our commitment to improving the wellbeing of staff patients and visitors. We are looking forward to further developing our partnership working as result of Outcomes Based Commissioning.


ANNEX 2

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 to prepare Quality Accounts for each financial year.

Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report.

In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2014/15 and supporting guidance

the content of the Quality Report is not inconsistent with internal and external sources of information including:

Board minutes for the period 1 April 2015 to 19th May

papers relating to quality reported to the board over the period 1 April 2015 to 19th May feedback from Commissioners, dated 19/05/2016

feedback from local Healthwatch organisations, dated 20/05/2016

feedback from Overview and Scrutiny Committee, dated 20/05/2016

the Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated [14 April 2016]

The national patient survey dated 2015

• The national staff survey dated 22/03/2016

• Care Quality Commission Intelligent Monitoring Report dated [28/05/2015]; and

• The Head of Internal Audit’s annual opinion over the Trust’s control environment; and

the Head of Internal Audit’s annual opinion over the Trust’s control environment, dated [31/03/2016]

the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered

the performance information reported in the Quality Report is reliable and accurate

there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice

the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and

the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) (published at www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor.gov.uk/annualreportingmanual).


The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the board NB: sign and date in any colour ink except black



23rd May 2016 23rd May 2016


Picture: Staff reaffirming their commitment making sure patients always have a good

experience of Kingston Hospital

Note: some of the figures for 2015/16 used in this report have not been independently verified at the time of writing.

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Appendix 1 – Sustainability Report 2015-16

Introduction

Sustainability means spending public money well, the smart and efficient use of natural resources and building healthy, resilient communities. By making the most of social, environmental and economic assets we can improve health both in the immediate and long term in the context of rising cost of natural resources.

Kingston Hospital NHS Foundation Trust (‘the Trust’) has this sustainability mission statement in our Carbon Management Plan (CMP):

"The Trust recognises it has a vital responsibility to minimise impact on the environment, prepare for changes in climate, ensure efficient resource use and maximise funds for patient care.

The Trust is committed to preventing pollution and reducing the environmental impact of its activities, and where reasonably practicable will comply with all relevant environmental legislation. The Trust will do all that is reasonably practicable, and considers it essential that all staff should work together positively to enable the Trust to comply with all Statutory Regulations and other best practice guidance relating to energy, the environment and sustainability.

The Trust recognises that global climate change is currently the greatest challenge facing humanity and commits itself to systematically reduce its greenhouse gas emissions. It is committed to developing and embedding a sustainable and carbon conscious culture throughout the organisation and all its activities by integrating carbon management within corporate strategies, policies and operational procedures. As a large employer in the local area the Trust will use its position to engage, inform and influence patients, visitors, staff and other local external organisations to encourage them to reduce their environmental impact."

As a part of the NHS public health and social care system the Trust will contribute towards the national target set in 2014 of reducing the carbon footprint of the NHS, public health and social care system by 34% (from a 1990 baseline) equivalent to a 28% reduction from a 2013 baseline by 2020.

Policies

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

Area Is sustainability considered?

Travel Yes

Procurement (environmental) Yes

Procurement (social impact) Yes

Suppliers' impact Yes

One of the objectives for the Trust for 2016/17 is to implement eClass for procurement (part of the NHS Procurement eEnablement Programme) see http://www.nhseclass.nhs.uk/ for more details. The Trust are in the process of developing a procurement policy that will have an expansive section on sustainability and how we will ensure the Trust’s procurement activity promotes sustainability and minimises any detrimental

http://www.nhseclass.nhs.uk/


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impact on the environment. The Trust will also include reference on how we will support the Social Value Act (2013) in our procurement activity.

One of the ways in which an organisation can embed sustainability is through the use of a Sustainable Development Management Plan or Carbon Reduction Management Plan. We have a Carbon Reduction Management Plan which is due to be reviewed and updated in January 2017.

As an organisation that acknowledges its responsibility towards creating a sustainable future, we help achieve that goal by running awareness campaigns that promote the benefits of sustainability to our staff.

Climate change brings new challenges to our business both in direct effects to the healthcare estates, but also to patient health. Examples of recent years include the effects of heat waves, extreme temperatures and prolonged periods of cold, floods, droughts etc. The board-approved plans address the potential need to adapt the delivery the organisation's activities and infrastructure to climate change and adverse weather events.

Partnerships

The NHS policy framework already sets the scene for commissioners and providers to operate in a sustainable manner, crucially for us as a provider evidence of this commitment will need to be provided in part through contracting mechanisms.

Strategic partnerships are already established Carbon Credentials and Carbon Architecture.

How the Trust Makes Decisions about Sustainability

The Trust’s Executive Management Committee is kept abreast of developments from the Trust’s Sustainability Steering Committee which has representation from various departments across the Hospital including both clinical and non-clinical staff. This committee acts as a focal point for all aspects of sustainability and energy reduction within the Trust such as staff engagement and implementation of energy efficient projects. The committee also engages with the wider Trust community to ensure that activities are varied, engaging and have a positive impact on the Hospital.

EMC

Sustainability Steering Committee

Staff Engagement Programme

Green Champions

Technical Carbon Management Projects


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Definitions

Scope 1 emissions are direct Green House Gas (GHG) emissions from sources that are owned or controlled by the entity. Scope 1 can include emissions from fossil fuels burned on site, emissions from entity-owned or entity-leased vehicles, and other direct sources.

Scope 2 emissions are indirect GHG emissions resulting from the generation of electricity, imported electricity, heating and cooling.

Scope 3 emissions include indirect GHG emissions from sources not owned or directly controlled by the entity but related to the entity’s activities. Scope 3 GHG emission sources currently required for GHG reporting include T&D losses associated with purchased electricity, employee travel and commuting, contracted solid waste disposal, and contracted wastewater treatment.

Performance

Since the 2007 baseline year, the NHS has undergone a significant restructuring process and one which is still on going. Therefore, in order to provide some organisational context, the following table may help explain how both the organisation and its performance on sustainability has changed over time. The Trust relinquished two outlying office buildings at the end of 2014/15 which is reflected in the reduced Floor Space measure below.

Context info 2007/08 2013/14 2014/15 2015/16

Floor Space (m2) 72,387 73,572 73,317 71,408

Number of Staff 2,305 2,683 2,700 2,700

As a part of the NHS, public health and social care system, it is our duty to contribute towards the level of ambition set in 2014 of reducing the carbon footprint of the NHS, public health and social care system by 34% (from a 1990 baseline) equivalent to a 28% reduction from a 2013 baseline by 2020. The carbon management plan which had a target of reducing our carbon emissions by 10% by 2015 is under review and we will be replacing it with a new 10 year plan that will run until 2025.

Summary of Performance

Area 2015/16 Performance Status

EU Emissions Trading scheme

Natural Gas & Fuel Oil

A decrease of 6.9% of CO2 emissions in calendar year 2015 compared with 2014 under the EU ETS.

Energy Consumption

Scope 1 & 2 In general, there was an 11% reduction in total energy consumption in financial year 2015/16 compared with 2014/15.

Waste Clinical waste The amount of clinical waste disposed increased by 2.5% from 2014/15 to 2015/16. This was due to increased activity over the past year.

General Waste General waste disposal increased by 0.2% from 2014/15 to 2015/16.


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Area 2015/16 Performance Status

Bulky Waste Bulky waste decreased by 27% from 2014/15 to 2015/16. This was due to renovations works inflating the figure for 2014/15. The 2015/16 figure is within 1% of the 2013/14 figure.

Reused/Recycled Waste

Recycled and reused waste has increased by 39.3% from 2014/15 to 2015/16. This is due to the site wide rollout of mixed recycling.

Water Water Supply & Waste Water Discharge

Water consumption and Wastewater emissions figures decreased by 24% from 2014/15 to 2015/16. This is partly due to the cessation of services to external buildings.

Comments A total of 5,196 carbon credits costing £21,000 were purchased from carbon trader to offset carbon credits deficit. Qualifying emissions under the EU ETS decrease by 6.9% in 2016 compared to 2015. The Hospital wide mixed recycling scheme commenced in December 2014 to reduce waste to landfill, carbon emissions and disposal costs. The main energy-reducing project for 2015/16 was the replacement of the windows in Esher Wing which was completed in October 2015. This will drastically improve the energy efficiency of that building.

Sustainability Accounting and Reporting This section sets out the Trust’s environmental data and the financial cost associated with energy consumption, waste management and water usage across the estate. The Trust’s gas and fuel oil data is also used for reporting CO2 emissions annually in the European Union Emissions Trading Scheme (EU ETS). The Trust is an Information Declarer in the Carbon Reduction Commitment (CRC) Energy Efficiency Scheme. This report sets out the annual achievements of the Trust in sustainability, found in the following areas:

Energy, Water and Waste Management

Sustainable Travel

Sustainability and Energy Awareness Programme

EU Emissions Trading Scheme (EU ETS) The EU ETS covers carbon emissions from combustion of gas and fuel oil from January to December of each year.

Year 2011 2012 2013 2014 2015 Chart

Tonnes of CO2e

6549 7288 7925 7429 6917

0

2000

4000

6000

8000

10000

2011 2012 2013 2014 2015

Tonnes of CO2e per Year


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Observations

CO2 emissions decreased by 6.9% between calendar years 2014 and 2015 under the EU ETS. A total of 5,196 carbon credits costing about £21,000 were purchased from carbon trader to offset carbon credits deficit.

This was due to reduced gas consumption caused by the CHP plant being shut down for maintenance during the year.

Energy Consumption

The Trust has spent £2,380,638 on energy in 2015/16, which is a minor decrease (0.5%) on energy spend from last year.

Resource 2013/14 2014/15 2015/16

Gas

Use (kWh) 46,453,100 44,037,200 39,004,154

tCO2e 9,855 9,239 8,183

Oil

Use (kWh) 17,500 49,400 94,105

tCO2e 6 16 30

Coal

Use (kWh) 0 0 0

tCO2e 0 0 0

Electricity

Use (kWh) 11,992,858 12,062,069 12,269,084

tCO2e 522 1,460 1,341

Green Electricity

Use (kWh) 0 0 0

tCO2e 0 0 0 Total Energy CO2e 10,383 10,715 9,554 Total Energy Spend £ 2,441,000 £ 2,393,000 £ 2,380,638

Observations

Gas consumption decreased by 11% in 2015/16 compared to 2014/15 due to reduced demand from the CHP plant while it was shut down for maintenance.

Oil consumption increased by 90% in 2015/16 compared to 2014/15. This was due to increased use of generators during essential works on the CHP plant.

Electricity consumption increased by 2% in 2015/16 compared to 2014/15.

Total spend on energy in 2015/16 was comparable with 2014/15.

0

2,000

4,000

6,000

8,000

10,000

12,000

2013/14 2014/15 2015/16

Car

bo

n (

tCO

2e

)

Carbon Emissions - Energy Use

Gas Oil Electricity


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Future Plans

Going forward, we expect a reduction in energy usage through more efficient heating in our largest ward block; Esher Wing. Work was completed in late 2015 to install new windows into this 19,000m² building. These replaced the original fittings and we expect a massive improvement in heat retention going forwards.

Reduce the amount of imported electricity purchased through awareness programmes to reduce energy consumption.

Smart Metering has been implemented across the site which allows the Trust to monitor the energy use of each building to target future efficiency plans.

A tendered project for Printers and Multi-functional devices is going ahead with implementation which should lead to the removal and/or replacement of older, less energy efficient hardware across the Trust including fax machines.

Continue to implement and update the Trust’s Carbon Management Plan and undertake further energy/CO2 emissions projects as detailed in the plan. This includes installing LED external lighting for car park, maintain momentum and embed Staff Energy Awareness programme, potential heating controls for some areas and upgrades to insulation. A full list of projects can be found on the Trust Carbon Management Plan.

Develop bids for funding of energy and CO2 emissions projects throughout the Trust.

Continue to monitor and report on energy consumption.

The Trust is working with Carbon Architecture and Veolia to review the CHP plant and make efficiencies where possible.

o A programme of works to increase the efficiency and effective use of the Low-Temperature Hot Water (LTHW) systems is under review for implementation in 2016/17.

o Connecting more LTHW load to the system by connecting more plant rooms to the CHP is planned for 2016/17 (cost £100k, payback 2.5 yrs.).

Waste Management

Waste 2013/14 2014/15 2015/16

Recycling

(tonnes) 101.70 150.00 208.92 tCO2e 2.14 3.15 4.39

Re-use (tonnes) 0.00 0.00 0.00

tCO2e 0.00 0.00 0.00

Compost (tonnes) 0.00 0.00 0.00

tCO2e 0.00 0.00 0.00

WEEE

(tonnes) 3.33 4.16 5.75 tCO2e 0.07 0.09 0.12

High Temp recovery

(tonnes) 0.00 0.00 0.00

tCO2e 0.00 0.00 0.00 High

Temp disposal

(tonnes) 96.42 131.90 90.16

tCO2e 21.21 29.02 19.83 Non-

burn disposal

(tonnes) 298.09 338.77 347.26

tCO2e 6.26 7.11 7.29

0.00

200.00

400.00

600.00

800.00

1000.00

1200.00

We

igh

t (t

on

ne

s)

Waste Breakdown

Recycling

WEEE

High Tempdisposal

Non-burndisposal

Landfill


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Landfill (tonnes) 487.74 472.00 473.10

tCO2e 119.21 115.37 115.63 Total Waste

(tonnes) 987.28 1096.83 1125.19 % Recycled or Re-

used 10% 14% 19% Total Waste tCO2e 148.89 154.74 147.26

Observations

Landfill waste remained unchanged in 2015/16 compared to 2014/15.

Non-Burn Disposal waste increased by 3% in 2015/16 compared to 2014/15.

High-Temperature Disposal waste decreased by approximately 30% in 2015/16 compared to 2014/15 this may be due to increased activity and the norovirus outbreaks.

WEEE increased by 38% in 2015/16 compared to 2014/15.

Recycling increased by 39% in 2015/16 compared to 2014/15. The Trust recycled 19% of all waste by tonnage.

The Hospital wide mixed recycling scheme commenced in December 2014 to reduce waste to landfill, carbon emissions and disposal costs. Since then, most desk bins have been eliminated and replaced with recycling facilities in each area.

In addition, the Trust saved £46k by re-selling outdated clinical equipment in 2015-16.

Future Plans

Implementation of a food waste recycling scheme across the Hospital site is being evaluated for implementation during 2016/17.

Introduction of a wood recycling scheme.

Recycling of single use instruments.

Green waste composting.

Waste Supply & Waste Water Discharge

Water 2013/14 2014/15 2015/16

Mains m3 41,095 43,330 32,940

tCO2e 37 39 30

Water & Sewage Spend £ 84,110 £ 85,000 £ 74,101

Observations

Water consumption and waste water discharge emissions reduced by 24% in the year 2015/16 compared with 2014/15. This is partly due to the cessation of services to external buildings.


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Future Plans

To continue to monitor water consumptions across the Trust.

Introduce energy efficient saving taps and showers systems.

Sustainable Travel

Carbon Emissions from Patient Transport

The Trust is in the process of implementing a new contract which will enable more accurate monitoring from April 2016 onwards.

Green Transport Initiatives

The Trust continues to develop its Healthy Transport Plan in conjunction with the local council. This is designed to encourage the use of alternate methods of transport and reduce the carbon footprint of staff.

All car parking application forms also offer information on cycling and loans for travel cards and improvements are being made to the public transport infrastructure in the immediate vicinity of the Trust.

The Trust continues to work towards improving the bus frequency and promoting additional services to areas poorly, or indirectly, served through feedback to Transport for London (TfL) and the Council. This year, the Trust worked with TfL to make improvements to the accessibility of the bus stops on the Hospital site.

The Trust continues to host a number of initiatives to improve awareness of green transport including Cycle Week and bike maintenance workshops. Additional bike sheds have been installed to encourage more staff and visitors to use bicycles. The Trust’s Cycle Scheme (which allows staff to purchase bicycles at preferential rates and spread payments over a year) continues to be popular, especially during the spring.

Sustainability and Energy Awareness Programme In September 2014, the Trust in partnership with Carbon Credentials launched a sustainability and energy awareness staff engagement programme. The aims of the programme were to:

Raise levels of awareness about the Trust’s environmental impact

Change attitudes and behaviours

Embed the responsible use of energy and other resources

Contribute to the Trust’s carbon reduction target

Achieve cost savings

Support patient care by creating comfortable environments

So far the Sustainability Scheme has brought about a highly successful Sustainability Awareness Week campaign which gave opportunity for Trust staff to submit ideas for future initiatives. Multiple staff got involved and a prize was awarded for the best suggestions.

The Green Champions project is still gaining momentum with more volunteers coming forward to promote green initiatives and responsibility locally around the Trust. The Trust is currently in the process of designing the next step in this project to identify high level Green Leaders to spearhead initiatives going forwards.

Kingston Hospital NHS Foundation Trust

Financial Statements 31st March 2016

23/05/2016

Contents

Foreword Page 1

Statement of Accounting Officer's Responsibilities Page 2

Statement Of Comprehensive Income Page 3

Statement Of Financial Position Page 4

Page 5

Statements Of Cash Flows Page 6

Notes to the Accounts Page 7 to Page 39

Statement Of Changes in Taxpayers' Equity

Kingston Hospital NHS Foundation Trust - Consolidated Annual Accounts 2015/16

Foreword to the Accounts

Kingston Hospital NHS Foundation Trust

These accounts for the year ended 31 March 2016 have been prepared by Kingston Hospital NHS

Foundation Trust in accordance with paragraphs 24 & 25 of Schedule 7 to the NHS Act 2006.

Signed

Ann Radmore

Chief Executive Officer

Date 23rd May 2016

Page 1


Statement of Accounting Officer's Responsibilities

Statement of the Chief Executive's responsibilities as the Accounting Officer of Kingston Hospital

NHS Foundation Trust.

The NHS Act 2006 states that the chief executive is the Accounting Officer of the NHS Foundation

Trust. The relevant responsibilities of the accounting officer, including their responsibility for the

propriety and regularity of public finances for which they are answerable, and for the keeping of

proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued

by Monitor.

Under the NHS Act 2006, Monitor has directed Kingston Hospital NHS Foundation Trust to prepare

for each financial year a statement of accounts in the form and on the basis set out in the Accounts

Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the

state of affairs of Kingston Hospital NHS Foundation Trust and of its income and expenditure, total

recognised gains and losses and cash flows for the financial year.

In preparing the accounts, the Accounting Officer is required to comply with the requirements of

the NHS Foundation Trust Annual Reporting Manual and in particular to:

disclosure requirements, and apply suitable accounting policies on a consistent basis;

Reporting Manual have been followed, and disclose and explain any material departures in the

financial statements;

and guidance; and

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

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

Ann Radmore

Chief Executive

Date 23rd May 2016

Page 2

STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED

Charitable

Funds

accounts 31

March 2016

Foundation

Trust accounts

31 March 2016

Group

accounts 31

March 2016

Charitable Funds

accounts 31

March 2015

Foundation

Trust

accounts 31

March 2015

Group

accounts 31

March 2015

Note £000 £000 £000 £000 £000 £000

Revenue

Revenue from Patient Care Activities 4 - 205,914 205,914 - 196,613 196,613

Other Operating Revenue 5 422 26,896 27,318 273 28,738 29,011

Total Operating Revenue 422 232,810 233,232 273 225,351 225,624

Employee Benefits 7 (136) (148,329) (148,465) (124) (135,181) (135,305)

Other Costs 7 (125) (92,346) (92,471) (511) (87,448) (87,959)

Total Operating Costs (261) (240,675) (240,936) (635) (222,629) (223,264)

Operating Surplus/ (Deficit) 161 (7,865) (7,704) (362) 2,722 2,360

Finance Costs

Investment Revenue 11 9 21 30 7 25 32

Finance Costs 12 - (3,481) (3,481) - (3,262) (3,262)

Surplus / (Deficit) for the Financial Period 170 (11,325) (11,155) (355) (515) (870)

Public Dividend Capital Dividends Payable - (3,035) (3,035) - (2,874) (2,874)

Retained Surplus / (Deficit) for the Year 170 (14,360) (14,190) (355) (3,389) (3,744)

Other Comprehensive Income

Impairments and reversals - (4,779) (4,779) - (2,341) (2,341)

Net gain on revaluation of property, plant and equipment - 9,063 9,063 - 5,762 5,762

Total Other Comprehensive Income - 4,284 4,284 - 3,421 3,421

Total Comprehensive Income for the Period 170 (10,076) (9,906) (355) 32 (323)

The notes on pages 7 to 39 form part of these accounts.

Charitable

Funds

accounts 31

March 2016

Foundation

Trust accounts

31 March 2016

Group

accounts 31

March 2016

Charitable Funds

accounts 31

March 2015

Foundation

Trust

accounts 31

March 2015

Group

accounts 31

March 2015

£000 £000 £000 £000 £000 £000

Reported Trust financial performance position (adjusted for

impairments)

Retained Surplus / (Deficit) for the Year 170 (14,360) (14,190) (355) (3,389) (3,744)

Impairments (excluding IFRIC 12 impairments included above) 15 - 7,299 7,299 - 3,654 3,654

Reported NHS financial performance position (adjusted

retained surplus / (deficit) ) 170 (7,061) (6,891) (355) 265 (90)

Add back: Inter-company Income / Expenditure eliminated on

consolidation (Donation from Charity to Trust capital

expenditure) (144) 144 0 0 0 0

Total Reported Surplus/ (Deficit) 26 (6,917) (6,891) (355) 265 (90)

b) Impairments to Fixed Assets: An impairment charge is not considered part of the Trust's operating position.


31 March 2016

a) IFRIC12 adjustment: The incremental revenue cost of bringing Private Finance Initiative assets onto the balance sheet (due to the introduction of International Financial

Reporting Standards accounting in 2009-10) which has no cash impact and is not chargeable for overall budgeting purposes, is not considered part of the Trust's operating

position.

The Trust's reported NHS financial performance position is derived from its retained deficit, adjusted for the following:

Page 3

STATEMENT OF FINANCIAL POSITION AS AT

31 March 2016

Charitable

Funds

accounts 31

March 2016

Foundation

Trust

accounts 31

March 2016

Group

accounts 31

March 2016

Charitable

Funds

accounts 31

March 2015

Foundation

Trust

accounts 31

March 2015

Group

accounts 31

March 2015

£000 £000 £000 £000 £000 £000

Non-current Assets

Property, Plant and Equipment 13 - 122,478 122,478 - 127,279 127,279

Intangible Assets 14 - 10,827 10,827 - 6,897 6,897

Trade and Other Receivables 18 - 246 246 - 209 209

Total Non-current Assets - 133,551 133,551 - 134,385 134,385

Current Assets

Inventories 17 - 1,396 1,396 - 878 878

Trade and Other Receivables 18 77 19,814 19,891 47 20,362 20,167

Cash and Cash Equivalents 19 2,782 4,372 7,154 3,248 6,419 9,667

Total Current Assets 2,859 25,582 28,441 3,295 27,659 30,712

Total Assets 2,859 159,133 161,992 3,295 162,044 165,097

Current Liabilities

Trade and Other Payables : Current 20 (9) (27,980) (27,989) (471) (26,784) (27,013)

Borrowings 21 - (1,660) (1,660) - (946) (946)

Other Liabilities 27 - (2,667) (2,667) - (2,417) (2,417)

Provisions 28 - (239) (239) - (362) (362)

Total Current Liabilities (9) (32,546) (32,555) (471) (30,509) (30,738)

Total Assets less Current Liabilities 2,850 126,587 129,437 2,824 131,535 134,359

Non-current Liabilities

Borrowings 21 - (34,423) (34,423) - (29,554) (29,554)

Provisions 28 - (1,166) (1,166) - (1,349) (1,349)

Total Non-current Liabilities - (35,589) (35,589) - 30,903- 30,903-

Total Assets Employed 2,850 90,998 93,848 2,824 100,632 103,456

Financed by Taxpayers' Equity

Public Dividend Capital - 59,034 59,034 - 58,737 58,737

Retained Earnings - 4,351 4,351 - 16,033 16,033

Revaluation Reserve - 27,613 27,613 - 25,862 25,862

Charitable Funds Reserve 37 2,850 - 2,850 2,824 - 2,824

Total Taxpayers' Equity 2,850 90,998 93,848 2,824 100,632 103,456

Signed on behalf of the Board by:

Ann Radmore

Chief Executive Officer

23rd May 2016

Note : Group accounts are net of inter-company transactions.


Page 4

Public Dividend

Capital

Retained

Earnings

Revaluation

Reserve

Charitable

funds reserve

Total

£000 £000 £000 £000 £000

Total balance at 1 April 2015 58,737 16,033 25,863 2,824 103,457

Public Dividend Capital received 297 - - - 297

Retained deficit for the year - (14,360) - - (14,360)

Transfers between reserves - 2,534 (2,534) - 0

Charity surplus for the year - - - 170 170

Impairments and reversals - - (4,779) - (4,779)

Net gain on revaluation of property, plant and equipment - - 9,063 - 9,063Other reserve movements: charitable funds consolidation

adjustment0 144 0 (144) 0

Net recognised revenue/(expense) for the year297 (11,682) 1,750 26 (9,609)

Balance at 31 March 2016 59,034 4,351 27,613 2,850 93,848

Public Dividend

Capital

Retained

Earnings

Revaluation

Reserve

Charitable

funds reserve

Total

£000 £000 £000 £000 £000

Total balance at 1 April 2014 58,064 19,422 22,441 3,179 103,107Public Dividend Capital received 673 - - - 673Retained surplus for the year - (3,389) - (3,389)Charity surplus for the year - - - (355) (355)Impairments and reversals - - (2,341) - (2,341)Net gain on revaluation of property, plant and equipment - - 5,762 - 5,762

Net recognised revenue/(expense) for the year 673 (3,389) 3,421 (355) 350

Balance at 31 March 2015 58,737 16,033 25,862 2,824 103,457


STATEMENT OF CHANGES IN TAXPAYERS' EQUITY

31 March 2016

Page 5

STATEMENT OF CASH FLOWS FOR THE YEAR ENDED

Charitable

Funds

accounts 31

March 2016

Foundation

Trust accounts

31 March 2016

Group

accounts 31

March 2016

Charitable

Funds accounts

31 March 2015

Foundation

Trust accounts

31 March 2015

Group accounts

31 March 2015

£000 £000 £000 £000 £000 £000

Cash flows from operating activities

Operating surplus / (deficit) 26 (7,729) (7,704) (362) 2,722 2,360

Depreciation and amortisation - 8,321 8,321 - 7,588 7,588

Impairments and reversals - 7,299 7,299 - 3,654 3,654

Interest paid - (167) (167) - - -

(Increase) in inventories - (518) (518) - (55) (55)

(Increase) / decrease in trade and other receivables (46) 404 358 - (6,553) (6,312)

(Decrease)/ increase in trade and other payables (446) 1,610 1,164 - 6,946 6,946

(Decrease)/increase in other current liabilities - 253 253 - (473) (473)

Provisions utilised - (324) (324) - (1,661) (1,661)

Consolidation of Charitable Funds working capital - (476) (476) 671 - 430

Net cash inflow / (outflow) from operating activities (466) 8,673 8,206 309 12,168 12,477

Cash flows from investing activities

Interest received - 21 21 7 25 32

Payments for property, plant and equipment - (7,750) (7,750) - (11,532) (11,532)

Payments for intangible assets - (2,474) (2,474) - (357) (357)

Net cash Inflow / (outflow) from investing activities - (10,203) (10,203) 7 (11,864) (11,857)

Net cash (outflow) / inflow before financing (466) (1,530) (1,997) 316 304 620

Cash flows from financing activities

Public dividend capital received - 297 297 - 673 673

Loans received from the Independent Trust Financing Facility - 6,650 6,650 - 3,350 3,350

PDC dividend paid - (3,109) (3,109) - (2,987) (2,987)

Interest on finance leases - (12) (12) - (20) (20)

Interest element of PFI - (3,276) (3,276) - (3,196) (3,196)

Capital element of payments in respect of finance leases and

on Statement of Financial Position PFI- (1,067) (1,067) - (705) (705)

Net cash outflow from financing - (517) (517) - (2,885) (2,885)

Net (decrease) / increase in cash and cash equivalents(466) (2,047) (2,514)

316 (2,581) (2,264)

Cash and cash equivalents at the beginning of the

financial year

3,248 6,419 9,668 2,932 9,000 11,932

Cash and cash equivalents at the end of the financial year 19 2,782 4,372 7,154 3,248 6,419 9,667


31 March 2016

Page 6

NOTES TO THE ACCOUNTS

1 Accounting Policies

Monitor has directed that the financial statements of NHS Foundation Trusts shall meet the accounting requirements of the

Foundation Trust Annual Reporting Manual (FT ARM), which shall be agreed with HM Treasury. Consequently, the following

financial statements have been prepared in accordance with the 2015-16 Annual Reporting Manual (ARM) issued by Monitor.

The accounting policies contained in that manual follow International Financial Reporting Standards and HM Treasury's FReM to

the extent that they are meaningful and appropriate to the NHS Foundation Trust. Where the Monitor ARM permits a choice of

accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the Trust for the

purpose of giving a true and fair view has been selected. The particular policies adopted by the Trust are described below. They

have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Accounting convention

These accounts have been prepared under the historical cost convention modified to account for the revaluation of property,

plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.

1.2 Accounting Standards issued but not yet adopted

Neither the HM Treasury Financial Reporting Manual nor the 2015-16 ARM require the following Standards and Interpretations to

be applied in 2015-16:

● IFRS 9 Financial Instruments – Application required for accounting periods beginning on or after 1 January 2018, but not yet

adopted by the FReM: early adoption is not therefore permitted

● IFRS 15 Revenue for Contracts with Customers - Application required for accounting periods beginning on or after 1 January

2017, but not yet adopted by the FReM: early adoption is not therefore permitted

● IFRS 16 Leases – Application required for accounting periods beginning on or after 1 January 2019, but not yet adopted by the

FReM: early adoption is not therefore permitted.

1.3 Acquisitions and discontinued operations

Activities are considered to be ‘acquired’ only if they are taken on from outside the public sector. Activities are considered to be

‘discontinued’ only if they cease entirely. They are not considered to be ‘discontinued’ if they transfer from one public sector body

to another.

1.4 Going concern

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, they continue to adopt the Going Concern basis in preparing the

accounts.


31 March 2016

Page 7

Accounting Policies (continued)

1.5 Critical accounting judgements and key sources of estimation uncertainty

In the application of the Trust’s accounting policies, management is required to make judgements, estimates and assumptions

about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and

associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results

may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting

estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the

revision and future periods if the revision affects both current and future periods.

1.5.1 Critical judgements in applying accounting policies

The following are the critical judgements, apart from those involving estimations (see below), that management has made in the

process of applying the Trust’s accounting policies and that have the most significant effect on the amounts recognised in the

financial statements:

a) The Trust has undertaken a review of all its leases and agreements and determined that two should be accounted for as a

finance lease under International Financial Reporting Standards (A service agreement with Huntleigh Healthcare Limited for Bed

Facilities Management and an agreement with Asteral (MES) Limited for the Operation of a Healthcare (CT Scanning) Facility), as

the Trust receives significantly all the risks and rewards under the terms of each agreement; and,

b) The Trust has two Private Finance Initiative schemes both of which have been accounted for under IFRIC 12 and are on

balance sheet under International Financial Reporting Standards.

c) The Trust has defined its buildings as specialised properties. This is due to the lack of a market for the Trust’s buildings for use

in a form outside the scope of a hospital. The buildings are therefore valued on a depreciated replacement cost basis, which is

normally on the basis of a modern equivalent asset.

1.5.2 Key sources of estimation uncertainty

The following are the key assumptions concerning the future, and other key sources of estimation uncertainty at the end of the

reporting period, that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities within

the next financial year:

a) NHS Litigation Authority member provisions. These provisions are subject to future outcome of litigation in progress. The

probabilities provided by the NHS Litigation Authority have been used to calculate the provision: and,

b) Pension provisions for staff and directors. The provision is based on life expectancies of each individual. Life expectancy

tables are used and these are obtained from the GAD website (up to 2006) and more recently from the Office of National

Statistics.

c) Land and Buildings valuations. All land and buildings are restated at fair value by way of annual professional valuations

carried out by an independent external valuer.

d) Asset lives. The reported amounts for depreciation of property, plant and equipment and amortisation of non-current

intangible assets can be materially affected by the judgements exercised in determining their estimated economic lives. Economic

lives are determined in a number of different ways such as valuations (external professional opinion) and physical asset

verification exercises. The minimum and maximum estimated economic lives of each class of asset are disclosed in Note 13.5

and 14.1 and the carrying values of property plant, and equipment and intangible assets in Note 13 and 14.

e) Accruals & Deferred income. Accruals are measured at the Directors' best estimate of the expenditure required to settle the

obligation for goods and services acquired at the balance sheet date. Deferred income is measured at the Directors' best estimate

of the income to be recognised after the balance sheet date for payments received for goods and services provided before the

balance sheet date.

f) Provision for Impairment of receivables. Provision is made as follows:

All debt categories excluding overseas visitor debt: Debts less than 180 days – No provision. Debts over 180 days – All debts

above a threshold value are reviewed individually to assess risk and value of known disputes. Provision is made to cover

disputed and amounts considered at significant risk of non-payment.

Overseas visitor debt: Debts over 365 days – Provision is made based upon historic recovery rate, after adjusting for write offs.

Provision of 100% is made for all debts greater than 2 years.


Page 8


1.6 Revenue

Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is

measured at the fair value of the consideration receivable. The main source of revenue for the Trust is from

commissioners for healthcare services. Revenue relating to patient care spells that are part-completed at the year

end are apportioned across the financial years on the basis of length of stay at the end of the reporting period

compared to expected total length of stay.

Where income is received for a specific activity that is to be delivered in the following year, that income is deferred.

The Trust receives income under the NHS Injury Cost Recovery Scheme, designed to reclaim the cost of treating

injured individuals to whom personal injury compensation has subsequently been paid e.g. by an insurer. The Trust

recognises the income when it receives notification from the Department of Work and Pensions' Compensation

Recovery Unit that the individual has lodged a compensation claim. The income is measured at the agreed tariff for

the treatments provided to the injured individual, less a provision for unsuccessful compensation claims and

doubtful debts.

1.7 Employee Benefits

1.7.1 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 leave 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.

1.7.2 Retirement benefit costs

Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an

unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under

the direction of the Secretary of State, in England and Wales. 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.

Employer pension cost contributions are charged to operating expenses as and when they become due.

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 expenditure at the time the Trust

commits itself to the retirement, regardless of the method of payment.

1.8 Expenditure on other goods and services

Expenditure on goods and services is recognised when, and to the extent that they have been received, and is

measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except

where it results in the creation of a non-current asset such as property, plant and equipment.

1.9 Property, plant and equipment

1.9.1 Recognition

Property, plant and equipment is capitalised if:

● It is held for use in delivering services or for administrative purposes; and,

● It is probable that future economic benefits will flow to, or service potential will be supplied to, the Trust; and,

● It is expected to be used for more than one financial year; and,

● The cost of the item can be measured reliably; and,

● The item has cost of at least £5,000; or,

● Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250,

where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to

have simultaneous disposal dates and are under single managerial control; or,

● Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their

individual or collective cost.


Page 9


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.

1.9.2 Valuation

All property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or

constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner

intended by management. All assets are measured subsequently at fair value.

Land and buildings used for the Trust’s services or for administrative purposes are stated in the statement of financial position at

their revalued amounts, being the fair value at the date of revaluation less any subsequent accumulated depreciation and

impairment losses. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially

different from those that would be determined at the end of the reporting period. Fair values are determined as follows:

● Land and non-specialised buildings – market value for existing use; and

● Specialised buildings - Modern Equivalent Asset (MEA) value, as adjusted for wear and tear.

Land and buildings are restated to fair value in accordance with IAS 16 and Monitor guidance, using professional valuations

every five years and an interim valuation on an annual basis to ensure that fair values are not materially different from the

carrying amounts. Valuations are carried out by professionally qualified valuers in accordance with the Royal Institute of

Chartered Surveyors (RICS) Appraisal and Valuation Manual based on MEA. A full valuation of land, buildings and dwellings

was carried out by Geraldeve (Independent Chartered Surveyors). Buildings were valued on a MEA basis as at 31 March 2016.

Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss.

Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by

International Accounting Standard (IAS 23) for assets held at fair value. Assets are revalued and depreciation commences when

they are brought into use.

Impairments that arise from a clear consumption of economic benefits or of service potential in the asset are charged to

operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an

amount equal to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve

attributable to that asset before the impairment.

An impairment that arises from a clear consumption of economic benefit or of service potential is reversed when, and to the

extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating income to the extent

that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining

reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the

revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the

impairment reversal is recognised.

Other impairments are treated as revaluation losses. Reversals of ‘other impairments’ are treated as revaluation gains.

Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised.

Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing

carrying value of the item replaced is written-out and charged to operating expenses.

1.10 Intangible assets

1.10.1 Recognition

Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the

Trust’s business or which arise from contractual or other legal rights. They are recognised only when it is probable that future

economic benefits will flow to, or service potential be provided to, the Trust; where the cost of the asset can be measured

reliably, and where the cost is at least £5,000.

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. Software that is integral to the operating of hardware, for example an operating system, is capitalised

as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for

example application software, is capitalised as an intangible asset. Expenditure on research is not capitalised: it is recognised

as an operating expense in the period in which it is incurred.

Internally-generated assets are recognised if, and only if, all of the following have been demonstrated:

● the technical feasibility of completing the intangible asset so that it will be available for use; and,

● The intention to complete the intangible asset and use it; and,

● The ability to sell or use the intangible asset; and,

● How the intangible asset will generate probable future economic benefits or service potential; and,

● The availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it; and

● The ability to measure reliably the expenditure attributable to the intangible asset during its development.


Page 10


1.10.2 Measurement

The amount initially recognised for internally-generated intangible assets is the sum of the expenditure incurred from

the date when the criteria above are initially met. Where no internally-generated intangible asset can be recognised,

the expenditure is recognised in the period in which it is incurred.

Following initial recognition, intangible assets are carried at fair value by reference to an active market, or, where no

active market exists, at amortised replacement cost (modern equivalent assets basis), indexed for relevant price

increases, as a proxy for fair value. Internally-developed software is held at historic cost to reflect the opposing

effects of increases in development costs and technological advances.

1.11 Depreciation, amortisation and impairments

Freehold land, properties under construction, and assets held for sale are not depreciated.

Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and

equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner

that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an

asset is the period over which the Trust expects to obtain economic benefits or service potential from the asset. This

is specific to the Trust and may be shorter than the physical life of the asset itself. Estimated useful lives and residual

values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held

under finance leases are depreciated over their estimated useful lives.

At each reporting period end, the Trust checks whether there is any indication that any of its tangible or intangible non-

current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount

of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet

available for use are tested for impairment annually.

A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an

impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and,

thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit should be

taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is

increased to the revised estimate of the recoverable amount but capped at the amount that would have been

determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure

to the extent of the decrease previously charged there and thereafter to the revaluation reserve.

Impairments are analysed between Departmental Expenditure Limits (DEL) and Annually Managed Expenditure

(AME) from 2011-12. This is necessary to comply with HM Treasury's budgeting guidance. DEL limits are set in the

Spending Review and Departments may not exceed the limits that they have been set.

AME budgets are set by HM Treasury and may be reviewed with departments in the run-up to the Budget.

Departments need to monitor AME closely and inform HM Treasury if they expect AME spending to rise above

forecast. Whilst HM Treasury accepts that in some areas of AME inherent volatility may mean departments do not

have the ability to manage the spending within budgets in that financial year, any expected increases in AME require

HM Treasury approval.

1.12 Donated assets

Donated non-current assets are capitalised at their fair value on receipt, with a matching credit to the donated asset

reserve. They are valued, depreciated and impaired as described above for purchased assets. Gains and losses on

revaluations, impairments and sales are as described above for purchased assets. Deferred income is recognised

only where conditions attached to the donation preclude immediate recognition of the gain.

1.13 Government grants

Following the accounting policy change outlined in the HM Treasury Financial Reporting Manual for 2011-12, a

government grant reserve is no longer maintained.

The value of assets received by means of a government grant are credited directly to income. Deferred income is

recognised only where conditions attached to the grant preclude immediate recognition of the gain.


Page 11


1.14 Leases

Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to

the lessee. All other leases are classified as operating leases.

1.14.1 The Trust as lessee

Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair

value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease

obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease

obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are

recognised in calculating the Trust’s surplus/deficit.

Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease

incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis

over the lease term.

Contingent rentals are recognised as an expense in the period in which they are incurred.

Where a lease is for land and buildings, the land and building components are separated and individually assessed

as to whether they are operating or finance leases.

1.14.2 The Trust as lessor

Amounts due from lessees under finance leases are recorded as receivables at the amount of the Trust’s net

investment in the leases. Finance lease income is allocated to accounting periods so as to reflect a constant

periodic rate of return on the Trust’s net investment outstanding in respect of the leases.

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.

1.15 Private Finance Initiative (PFI) transactions

HM Treasury has determined that government bodies shall account for infrastructure PFI schemes where the

government body controls the use of the infrastructure and the residual interest in the infrastructure at the end of the

arrangement as service concession arrangements, following the principles of the requirements of IFRIC 12. The

Trust therefore recognises the PFI asset as an item of property, plant and equipment together with a liability to pay

for it. The services received under the contract are recorded as operating expenses.

The annual unitary payment is separated into the following component parts, using appropriate estimation

techniques where necessary:

a) Payment for the fair value of services received;

b) Payment for the PFI asset, including finance costs; and

c) Payment for the replacement of components of the asset during the contract 'lifecycle replacement'.


Page 12


1.15.1 Services received

The fair value of services received in the year is recorded under the relevant expenditure headings within ‘operating

expenses’.

1.15.2 PFI asset

The PFI assets are recognised as property, plant and equipment, when they come into use. The assets are

measured initially at fair value in accordance with the principles of International Accounting Standards 17.

Subsequently, the assets are measured at fair value, which is kept up to date in accordance with the Trust’s

approach for each relevant class of asset in accordance with the principles of International Accounting Standard 16.

1.15.3 PFI liability

A PFI liability is recognised at the same time as the PFI assets are recognised. It is measured initially at the same

amount as the fair value of the PFI assets and is subsequently measured as a finance lease liability in accordance

with International Accounting Standard 17.

An annual finance cost is calculated by applying the implicit interest rate in the lease to the opening lease liability for

the period, and is charged to ‘Finance Costs’ within the Statement of Comprehensive Income.

The element of the annual unitary payment that is allocated as a finance lease rental is applied to meet the annual

finance cost and to repay the lease liability over the contract term.

An element of the annual unitary payment increase due to cumulative indexation is allocated to the finance lease. In

accordance with International Accounting Standards 17, this amount is not included in the minimum lease payments,

but is instead treated as contingent rent and is expensed as incurred. In substance, this amount is a finance cost in

respect of the liability and the expense is presented as a contingent finance cost in the Statement of Comprehensive

Income.

1.15.4 Lifecycle replacement

Components of the asset replaced by the operator during the contract (‘lifecycle replacement’) are capitalised where

they meet the Trust’s criteria for capital expenditure. They are capitalised at the time they are provided by the

operator and are measured initially at their fair value.

The element of the annual unitary payment allocated to lifecycle replacement is pre-determined for each year of the

contract from the operator’s planned programme of lifecycle replacement. Where the lifecycle component is

provided earlier or later than expected, a short-term finance lease liability or prepayment is recognised respectively.

Where the fair value of the lifecycle component is less than the amount determined in the contract, the difference is

recognised as an expense when the replacement is provided. If the fair value is greater than the amount determined

in the contract, the difference is treated as a ‘free’ asset and a deferred income balance is recognised. The deferred

income is released to the operating income over the shorter of the remaining contract period or the useful economic

life of the replacement component.

1.15.5 Assets contributed by the Trust to the operator for use in the scheme

Assets contributed for use in the scheme continue to be recognised as items of property, plant and equipment in the

Trust’s Statement of Financial Position.

1.15.6 Other assets contributed by the Trust to the operator

Assets contributed (e.g. cash payments, surplus property) by the Trust to the operator before the asset is brought

into use, which are intended to defray the operator’s capital costs, are recognised initially as prepayments during the

construction phase of the contract. Subsequently, when the asset is made available to the Trust, the prepayment is

treated as an initial payment towards the finance lease liability and is set against the carrying value of the liability.

1.16 Inventories

Inventories are valued at the lower of cost and net realisable value using the first-in first-out cost formula. This is

considered to be a reasonable approximation to fair value due to the high turnover of stocks.


Page 13

1. Accounting Policies (continued)

1.17 Cash and cash equivalents

Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than

24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are

readily convertible to known amounts of cash with insignificant risk of change in value.

In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on

demand and that form an integral part of the Trust’s cash management.

1.18 Provisions

Provisions are recognised when the Trust has a present legal or constructive obligation as a result of a past event, it

is probable that the Trust will be required to settle the obligation, and a reliable estimate can be made of the amount

of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the

obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is

measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those

cash flows using HM Treasury’s discount rate of 1.37% in real terms.

When some or all of the economic benefits required to settle a provision are expected to be recovered from a third

party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the

amount of the receivable can be measured reliably.

Present obligations arising under onerous contracts are recognised and measured as a provision. An onerous

contract is considered to exist where the Trust has a contract under which the unavoidable costs of meeting the

obligations under the contract exceed the economic benefits expected to be received under it.

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.

1.19 Clinical negligence costs

The NHS Litigation Authority operates a risk pooling scheme under which the Trust pays an annual contribution to the

NHS Litigation Authority which in return settles all clinical negligence claims. The contribution is charged to

expenditure. Although the NHS Litigation Authority 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 NHS Litigation

Authority on behalf of the Trust is disclosed at note 28.

1.20 Non-clinical risk pooling

The Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk

pooling schemes under which the Trust pays an annual contribution to the NHS Litigation Authority and, in return,

receives assistance with the costs of claims arising. The annual membership contributions, and any excesses

payable in respect of particular claims are charged to operating expenses as and when they become due.

1.21 Contingencies

A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only

by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the Trust,

or a present obligation that is not recognised because it is not probable that a payment will be required to settle the

obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed

unless the possibility of a payment is remote.

A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the

occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the Trust. A

contingent asset is disclosed where an inflow of economic benefits is probable.

Where the time value of money is material, contingencies are disclosed at their present value.


Page 14


1.22 Financial assets

Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items

(such as goods or services), which are entered into in accordance with the Trust’s normal purchase, sale or usage

requirements, are recognised when, and to the extent which, performance occurs, i.e., when receipt or delivery of the

goods or services is made.

Financial assets are initially recognised at fair value, which is determined by reference to quoted market prices

where possible.

Financial assets are classified into the following categories: financial assets at fair value through profit and loss; held

to maturity investments; available for sale financial assets, and loans and receivables. The classification depends

on the nature and purpose of the financial assets and is determined at the time of initial recognition.

1.22.1 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 of current investments, 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.

If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively

to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed

through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed

does not exceed what the amortised cost would have been had the impairment not been recognised.

1.23 Financial liabilities

Financial liabilities are recognised on the statement of financial position when the Trust becomes party to the

contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have

been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has

been paid or has expired.

Loans from the Department of Health are recognised at historical cost. Otherwise, financial liabilities are initially

recognised at fair value, which is determined by reference to quoted market prices where possible.

1.24 Value Added Tax (VAT)

Most of the activities of the Trust are outside the scope of VAT and, in general, output tax does not apply and input

tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included

in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the

amounts are stated net of VAT.

1.25 Foreign currencies

The Trust's functional currency and presentational currency is sterling. Transactions denominated in a foreign

currency are translated into sterling at the exchange rate ruling on the dates of the transactions. At the end of the

reporting period, monetary items denominated in foreign currencies are retranslated at the spot exchange rate on 31

March. Resulting exchange gains and losses for either of these are recognised in the Trust’s surplus/deficit in the

period in which they arise.

1.26 Third party assets

Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since

the Trust has no beneficial interest in them. Details of third party assets are disclosed at note 35.


Page 15


1.27 Public Dividend Capital (PDC) and Public Dividend Capital Dividend

Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment

of the predecessor NHS Trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32.

A charge, reflecting the cost of capital utilised by the NHS Foundation Trust, is payable as public dividend capital dividend. The charge is

calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS foundation trust during the financial

year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets (including lottery

funded assets), (ii) average daily cash balances held with the Government Banking Services (GBS) and National Loans Fund (NLF) deposits,

excluding cash balances held in GBS accounts that relate to a short-term working capital facility, and (iii) any PDC dividend balance receivable

or payable. In accordance with the requirements laid down by the Department of Health (as the issuer of PDC), the dividend for the year is

calculated on the actual average relevant net assets as set out in the “pre-audit” version of the annual accounts. The dividend thus calculated is

not revised should any adjustment to net assets occur as a result the audit of the annual accounts.

1.28 Losses and special payments

Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed

legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with

the generality of payments. They are divided into different categories, which govern the way that individual cases are handled.

Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would

have been made good through insurance cover had NHS trusts not been bearing their own risks (with insurance premiums then being included

as normal revenue expenditure).

1.29 Research and development

Research and development expenditure is charged against income in the year in which it is incurred, except insofar as development expenditure

relates to a clearly defined project and the benefits of it can reasonably be regarded as assured. Expenditure so deferred is limited to the value

of future benefits expected and is amortised through the Operating Cost Statement on a systematic basis over the period expected to benefit

from the project. It should be revalued on the basis of current cost. The amortisation is calculated on the same basis as depreciation, on a

quarterly basis.

1.30 Consolidation

The NHS foundation trust is the corporate trustee to Kingston Hospital Charitable Fund. The foundation trust has assessed its relationship to the

charitable fund and determined it to be a subsidiary because the foundation trust is exposed to, or has rights to, variable returns and other

benefits for itself, patients and staff from its involvement with the charitable fund and has the ability to affect those returns and other benefits

through its power over the fund.

The charitable fund's statutory accounts are prepared to 31 March in accordance with the UK Financial Reporting Standard (FRS) 102. On

consolidation, necessary adjustments are made to the charity's assets, liabilities and transactions to:

- recognise and measure them in accordance with the foundation trust's accounting policies; and

- eliminate intra-group transactions, balances, gains and losses.

The charitable fund's key accounting policies in relation to its funds are as follows:

Funds structure

Incoming resources and resources expended are allocated to particular funds according to their purpose. Transfers between funds may arise

where there is an authorised release of restricted or endowment funds, or when charges are made from unrestricted to other funds.

Permanent endowment funds

Funds where the capital is held to generate income for charitable purposes and cannot itself be spent, are accounted for as permanent

endowment funds.

Restricted funds

Restricted funds include those receipts which are subject to specific restrictions imposed by the donor or trust charitable funds procedures,

usually in writing.

Unrestricted funds

Unrestricted funds include income received without restriction. Unrestricted funds are available for use at the discretion of the trustees in

furtherance of the general objectives of the charity. The trustee may earmark unrestricted funds for a particular purpose without restricting or

committing the funds legally. Such amounts are known as designated funds.

1.31 Joint operations

Joint operations are arrangements in which the Trust has joint control with one or more other parties and has the rights to the assets, and

obligations for the liabilities, relating to the arrangement. The Trust includes within its financial statements its share of the assets, liabilities,

income and expenses.

The Trust has a contractural joint arrangement between Kingston Hospital NHS Foundation Trust, St Georges Healthcare NHS Foundation

Trust, and Croydon Health Services NHS Trust to provide pathology services to primary and secondary acute and non-acute and private sector

healthcare providers in South West London.

1.32 Revaluation Reserve

The Trust reviews it's assets on a regular basis to ensure that the carrying amount of an asset does not differ materiality from that which would

be determined with a fair value at the end of the period. This comprises the revaluation reserve.

1.33 Retained Earnings

Retained earnings denote the balance of the surplus/ (deficit) of the Trust since it's inception. Retained Earnings is stated prior to taking into

account any gains or losses on impairments and reversals / revaluations.


Page 16

2 Operating Segments for the year ended 31 March 2016

3 Income Generation Activities

The Trust does not undertake any non healthcare income generating activities that have full costs in excess of £1m.

4 Revenue from Patient Care Activities

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000

CCGs and NHS England 200,573 193,126

Local Authorities 3,507 1,344

NHS other 49 47

Non-NHS:

- Private patients 408 514

- Overseas patients (non-reciprocal) 336 333

- Injury costs recovery 528 487

- Other 513 763

Total 205,914 196,613

Total income from Commissioner Requested Services of £200,573k is included above (2014/15 £193,126k)

5 Other Operating Revenue

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000

Education, training and research 9,035 8,676

Non-patient care services to other bodies 9,207 9,332

Other income generation 5,636 7,728

Rental revenue 1,198 1,116

Staff recharge income 1,820 1,887

Charitable and other contributions to expenditure 422 273 Total 27,318 29,011

6 Overseas visitors (relating to patients charged directly by the foundation trust)

Group

accounts 31

March 2016

Group

accounts 31

March 2015

Total Total

£000 £000

Income recognised this year 336 333

Cash payments received in-year (relating to invoices raised in current and previous years) 160 116

52 (191)

Amounts written off in-year (relating to invoices raised in current and previous years) 0 (20)


Injury cost recovery income is subject to a provision for impairment of receivables of 15.8% to reflect expected rates of collection.

Amounts added to provision for impairment of receivables (relating to invoices raised in current

and prior years)

The nature of the Trust's services is the provision of healthcare. Similar methods are used to provide services trust-wide, and

policies, procedures and governance arrangements apply trust-wide. As an NHS Foundation Trust, all services are subject to the

same regulatory environment and standards. Accordingly, the Trust operates a single segment: healthcare.

Page 17

Group

accounts 31

March 2016

Group accounts

31 March 2015

7 Operating Expenses £000 £000

Employee benefits excluding Non Executive Board members (included with note 9.1) 148,196 135,042

Charitable Funds Pay costs (included with note 9.1) 136 124

Non Executive Board members 133 141

Supplies and services - clinical 14,743 17,881

SWL Pathology Supplies and Services - Clinical 9,339 8,549

Drug inventories consumed 18,496 17,120

Supplies and services - general 1,777 630

Consultancy services 501 1,820

Internal audit costs 48 47

Establishment 2,092 2,039

Transport 1,525 1,340

Premises 19,620 18,341

Impairments and reversals of receivables 0 843

Change in provisions discount rate(s) 44 83

Depreciation 6,478 6,389

Amortisation 1,843 1,199

Impairments and reversals of property, plant and equipment 7,299 3,654

Audit services - statutory audit 48 64

Other auditor's remuneration 24 - Clinical negligence (excess payments associated with NHSLA) 4,764 4,876

Training, courses and conferences 1,228 469

Rentals under operating leases - minimum lease payments 731 1,003

Other 1,610 1,151

Charitable Funds non pay costs 261 459 Total 240,936 223,264

8 Operating Leases

8.1 As lessee

8.1.1 Payments recognised as an expense

Group

accounts 31

March 2016

Group accounts

31 March 2015

£000 £000

Total Minimum lease payments 731 1,003


Grant Thornton are the external auditors of Kingston Hospital Charity, of which the Trust is the corporate trustee. The fees in respect of

this engagement are £5,000 (2014/15 £5,000).

Other operating expenses include healthcare services from South West London and St Georges Mental Health NHS Trust of £0.4m;

£0.3m of services from Your Health; and Central Surrey Health.

Page 18

8 Operating Leases (continued)

Group

accounts 31

March 2015

Land Buildings Other Total Total

£000 £000 £000 £000 £000

Payable:

Not later than one year 0 425 55 480 534

Between one and five years 0 1,370 114 1,484 1,538

After five years 0 5,867 0 5,867 5,927

Total 0 7,662 169 7,831 7,999

8.2 Rental revenue Group

accounts

31 March

2016

Group

accounts 31

March 2015

£000 £000

Rent 501 600

Contingent rent 697 515

Total rental revenue 1,198 1,115

9

9.1 Employee benefits

Group

accounts 31

March 2015

£000

Permanently

employed

Other Total Total

£000 £000 £000 £000

Salaries and wages 97,924 1,522 99,446 94,065

Social security costs 9,357 - 9,357 8,849

12,783 - 12,783 12,136

Bank and Agency - 26,897 26,897 20,254

Charitable Funds 136 - 136 124 120,200 28,419 148,619 135,428

287 - 287 264119,913 28,419 148,332 135,164

Group accounts 31 March 2016

Employer contributions to NHS Pension scheme

Gross employee benefits

Less: Employee costs capitalised

Net employee benefits excluding capitalised costs

Rental revenue includes £0.9m (£0.8m 2014/15) for the lease of floor space to BMI Healthcare, and £0.3m (£0.3m 2014/15) for the lease

of roof space for telecoms masts.


8.1.2 Total future minimum lease

payments


Employee Benefits and Staff Numbers

9.1.1 Employee benefits

Page 19

9

9.2

Permanently

employed

Other Total Group

accounts 31

March 2015

Number Number Number Number

Medical and dental 387 - 387 382

546 - 546 471

418 - 418 425

827 - 827 787

249 - 249 248

Other - Agency and Bank 68 533 601 456

Total 2,495 533 3,028 2,769

Of the above:

7 6

9.3 Staff sickness absence Group

accounts

31 March

2016

Group

accounts 31

March 2015

Number Number

Total days lost 16,619 15,957

Total staff years 2,461 2,414

Average working days lost 7 7

£'000 Number

9.3.1

60 1

9.4

Compulsory

redundancies

Other agreed

departures

Total Group

accounts 31

March 2015

Number Number Number Number

Less than £10,000 - 4 4 -

£10,001 to £25,000 - - - -

£25,001 to £50,000 - 2 2 -

£50,001 to £100,000 - - - -

£100,001 to £150,000 - - - -

£150,001 to £200,000 - - - -

> £200,001 - - - -

Total - 6 6 -

Total resource cost £000 - 87 87 -

Group accounts 31 March

2016


Employee Benefits and Staff Numbers

Average number of

people employed


Administration and estates

Healthcare assistants and other support staff

The table above includes the number and total value of exit packages taken by staff leaving in the period. The

expense associated with these departures may have been recognised in part or in full in a previous year.

Redundancy and other departure costs have been paid in accordance with the provisions of the NHS Pension

Scheme. Where the Trust has agreed early retirements the additional costs are met by the Trust and not by the

NHS Pension Scheme. Ill-health retirement costs are met by the NHS Pension Scheme and are not included in

the Trust's financial position. During the financial year 2015-16, there was one ill-health retirement, at a cost of

£60k. (2014-15, 3 ill health retirements at a cost of £178k)

Number and cost of persons retiring on ill

health grounds

Exit packages agreed Group accounts 31 March 2016

Nursing, midwifery and health visiting staff

Scientific, therapeutic and technical staff

Number of whole time equivalent staff

engaged on capital projects

Page 20

9

9.5 Pension Costs

9.5.1 Full actuarial (funding) valuation

9.5.2 Accounting valuation

.

9.5.3 Scheme provisions

The scheme is a “final salary” scheme. Annual pensions are normally based on 1/80th for the 1995 section and of

the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of

reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have

their annual pensions based upon total pensionable earnings over the relevant pensionable service.

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking

into account their recent demographic experience), and to recommend contribution rates payable by employees and

employers.

The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31

March 2012.

The Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health,

with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and appropriate employee

and employer representatives as deemed appropriate.

A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s

Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting

period in conjunction with updated membership and financial data for the current reporting period, and are accepted

as providing suitably robust figures for financial reporting purposes. The valuation of scheme liability as at 31 March

2016, is based on valuation data as 31 March 2015, updated to 31 March 2016 with summary global member and

accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM

interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of

the annual NHS Pension Scheme (England and Wales) Pension Accounts. These accounts can be viewed on the

NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.


Employee Benefits and Staff Numbers (continued)

Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits

payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.

Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed

under the direction of the Secretary of State in England and Wales. They are 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, each

scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each

scheme is taken as equal to the contributions payable to that 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:

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:

Page 21

9

Members can purchase additional service in the NHS Scheme and contribute to money purchase AVCs run by the

Scheme’s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers.


Employee Benefits and Staff Numbers (continued)

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 Price 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.

Page 22

9.6 Salary and Pension entitlements of senior managers

a) Remuneration

Salary paid

Taxable

Benefits

Annual

Performance

Related

Bonus

Payments

Long-term

Performance

Related

Bonus

Payments

Pension-

related

Benefits Total

(bands of

£5,000)

(rounded to

the nearest

£'000)

(bands of

£5,000)

(bands of

£5,000)

(bands of

£2,500)

(bands of

£5,000)

Ann Radmore, Interim Chief Executive from September 2015 55-60 - - - 7.5-10 65-70

Kate Grimes, Chief Executive until March 2016 220-225 - - - 165-167.5 385-390

Eileen Doyle, Interim Chief Operating Officer from August 2015 145-150 - - - - 145-150

Dr Charles Bruce, Deputy Chief Executive until June 2015 60-65 - - - (5)-(2.5) 60-65

Duncan Burton, Director of Nursing and Patient Experience 120-125 - - - 75-77.5 195-200

Jo Farrar, Director of Finance from April 2015 130-135 - - - 32.5-35 165-170

Jane Wilson, Medical Director 190-195 - - - 5-7.5 200-205

Rachel Benton, Director of Strategic Development 120-125 - - - 85-87.5 205-210

Terry Roberts, Director of Workforce until February 2016 95-100 - - - 55-57.5 155-160

Anne Robson, Interim Director of Workforce from March 2016 20-25 - - - - 20-25

Nicola Hunt, Director of Productivity, Innovation & Improvement until June 2015 20-25 - - - 0-2.5 20-25

Sylvia Hamilton, Non-Executive Director from January 2016 0-5 - - - - 0-5

Candace Imison, Non-Executive Director until August 2015 5-10 - - - - 5-10

Michael Jennings, Non-Executive Director until March 2016 10-15 - - - - 10-15

Joan Mulcahy, Non-Executive Director 10-15 - - - - 10-15

Jacqueline Unsworth, Non-Executive Director 10-15 - - - - 10-15

Sian Bates, Trust Board Chairman 45-50 - - - - 45-50

Chris Streather, Non-Executive Director 10-15 - - - - 10-15

Martin Grazier, Non-Executive Director 10-15 - - - - 10-15

b) Pension Benefits

Name and title

Real increase

in pension at

age 60

Real

increase in

pension

lump sum at

age 60

Total accrued

pension at

age 60 at 31

March 2016

Lump sum

at age 60

related to

accrued

pension at

31 March

2016

Cash

Equivalent

Transfer

Value at 1

April 2015

Real

Increase in

Cash

Equivalent

Transfer

Value

Cash

Equivalent

Transfer

Value at 31

March 2016

Employer's

contribution

to

stakeholder

pension

(bands of

£2500)

£000

(bands of

£2500)

£000

(bands of

£5000)

£000

(bands of

£5000)

£000

£000 £000 £000 £'000

Kate Grimes (Chief Executive until March 2016) 7.5-10 22.5-25 60-65 190-195 995 0 0 26

Ann Radmore, Interim Chief Executive from September 2015 0-2.5 2.5-5 65-70 205-210 1,383 44 1,443 22

Dr Charles Bruce (Deputy Chief Executive until June 2015) 0-2.5 0-2.5 35-40 105-110 687 6 701 3

Duncan Burton (Director of Nursing and Patient Experience) 2.5-5 5-7.5 25-30 70-75 294 44 341 17

Nicola Hunt (Director of Productivity, Innovation & Improvement until June 2015)0-2.5 -2.5-0 5-10 25-30 119 2 122 3

Jo Farrar (Director of Finance) 2.5-5 0-2.5 15-20 45-50 241 27 271 19

Jane Wilson (Medical Director) 0-2.5 5-7.5 70-75 220-225 1,501 57 1,576 24

Rachel Benton (Director of Strategic Development) 2.5-5 7.5-10 30-35 95-100 480 69 555 18

Terry Roberts (Director of Workforce until February 2016) 2.5-5 0-2.5 25-30 65-70 328 33 365 13

c) Fair Pay Multiple

Real Increase in CETV for the current year may be different from the prior year. In July 2010 the Chancellor announced that the uprating (annual increase) of public sector pensions

would change from the Retail Price Index (RPI) to the Consumer Prices Index (CPI). As a result the Government Actuaries Department undertook a review of all transfer factors.

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 mid-point of the banded remuneration of the highest-paid director in Kingston Hospital NHS Foundation Trust, in the financial year 2015-16 was £192,500 (2014-15 £192,500)

excluding contractural payments in lieu of notice. This was 5.5 times (5.4 times in 2014-15) the median remuneration of the workforce, which was £35,000 (2014-15 median

remuneration £35,900)Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind as well as severance payments. It does not include employer pension contributions and

the Cash Equivalent Transfer Value of pensions.


Name and Title

There were no payments in the year in respect of "golden hellos", compensation for loss of office, or benefits in kind for any of the senior managers. As Non Executive Directors do not

receive pensionable remuneration, there are no entries in respect of pensions for Non Executive Directors.

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 amounts, and from 2004-05 the other pension amounts, 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 pensionable 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.

Page 23

10 Better Payment Practice Code

10.1

Number £000 Number £000

Total Non-NHS trade invoices paid in the year 52,768 85,351 49,391 73,552

Total Non NHS trade invoices paid within target 19,691 48,016 36,789 60,362Percentage of Non-NHS trade invoices paid within target 37% 56% 74% 82%

11 Investment Revenue

Group

accounts 31

March 2016

Group

accounts

31 March

2015

£000 £000

Interest income:

- Bank interest - Trust 21 25

- Bank interest - Charity 9 7

Total 30 32

12 Finance Costs 2015-16 Group

accounts

31 March

2015

£000 £000

Interest on obligations under finance leases 12 20

Provisions - unwinding of discount 18 20

Capital loan from Department of Health interest 167 26

Interest on obligations under PFI contracts:

- main finance cost 3,284 3,196

Total interest expense 3,481 3,262

Group accounts 31 March

2015


Measure of compliance Group accounts 31 March

2016

The Better Payment Practice Code requires the Trust to aim to pay all undisputed Non-NHS invoices by the due date or

within 30 days of receipt of goods or a valid invoice, whichever is later.

Page 24

13 Property, Plant and Equipment

13.1 at 31 March 2016

Land Buildings

excluding

dwellings

Assets under

construction

Plant and

machinery

Information

technology

Furniture

and fittings

Total

£000 £000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 2015 26,930 74,421 9,206 21,196 5,563 1,901 139,217

Additions purchased - 801 3,788 1,418 1,674 167 7,848

Additions donated - 144 - - - - 144

Reclassifications - 7,165 (10,014) 281- - (169) (3,299)

Derecognition - - - - - - -

Impairments charged to operating expenses (6,760) (539) - - - - (7,299)

Upward revaluation gains - 9,063 - - - - 9,063

Cumulative depreciation adjustment following revaluation - - - - - - -

Impairments charged to reserves (930) (3,849) - - - - (4,779)

Cost or valuation at 31 March 2016 19,240 87,206 2,980 22,333 7,237 1,899 140,895

Depreciation at 1 April 2015 - - - 11,557 2,567 1,488 15,612

Derecognition - - - - - - -

Cumulative depreciation adjustment following revaluation - (3,673) - - - - (3,673)

Charged during the year - 3,673 - 1,622 1,123 60 6,478

Depreciation at 31 March 2016 - - - 13,179 3,690 1,548 18,417

Net book value at 31 March 2016 19,240 87,206 2,980 9,154 3,547 351 122,478

Asset financing

Owned 19,240 65,597 2,980 6,399 3,548 351 98,115

Donated - 4,109 - 283 - - 4,392

Held on finance leased - - - 2,472 - - 2,472

Private finance initiative - 17,499 - - - - 17,499



Page 25

13 Property, Plant and Equipment

13.2 At 31 March 2015

Land Buildings

excluding

dwellings

Assets under

construction

Plant and

machinery

Information

technology

Furniture and

fittings

Total

£000 £000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 2014 26,000 78,159 5,854 25,988 9,213 2,629 147,843

Additions purchased - 3,480 6,229 1,538 417 - 11,664

Reclassifications - 1,355 (2,877) 477 - (1,045)

Derecognition - - - (6,331) (4,544) (728) (11,603)

Impairments charged to operating expenses - (3,654) - - - - (3,654)

Upward revaluation gains 930 4,832 - - - - 5,762


Impairments charged to reserves - (2,341) - - - - (2,341)

Reversal of impairments charged to reserves - - - - - - -

Cost or valuation at 31 March 2015 26,930 78,093 9,206 21,195 5,563 1,901 142,888

Depreciation at 1 April 2014 - 50 - 16,282 6,172 2,057 24,561

Reclassifications - - - - - - -

Derecognition - - - (6,331) (4,544) (728) (11,603)


Charged during the year - 3,688 - 1,605 938 158 6,389

Depreciation at 31 March 2015 - - - 11,556 2,566 1,487 15,6090Net book value at 31 March 2015 26,930 78,093 9,206 9,639 2,997 414 127,279

Asset financing

Owned 26,930 55,553 9,206 6,731 2,997 414 101,831

Donated - 4,027 - 436 - - 4,463

Held on finance leased - - - 2,472 - - 2,472

Private finance initiative - 18,513 - - - - 18,513


Kingston Hospital NHS Foundation Trust - Annual Accounts 2015/16

Page 26

13 Property, Plant and Equipment (continued)

13 Donated assets

13 Property revaluation

14 Economic lives Minimum Life Maximum Life

Years Years

Buildings excluding dwellings 5 70

Plant and machinery 5 30

Information technology 5 12

Furniture and fittings 5 22


Kingston Hospital NHS Foundation Trust General Charitable Fund contributed £56,425 towards patient related

welfare programmes and £88,023 towards equipment during the year ended 31 March 2016.

A full valuation was undertaken for the Trust’s freehold properties as at 31 March 2016 by an external valuer, Gerald

Eve LLP, a regulated firm of Chartered Surveyors. The valuation was prepared in accordance with the requirements

of the RICS Valuation Standards, Eighth Edition, March 2014, the International Valuation Standards and IFRS. The

valuation of these properties was on the basis of Fair Value primarily derived using the Depreciated Replacement

Cost (DRC) method and the valuation is subject to the prospect and viability of the continued occupation and use.

Page 27

14 Intangible Assets Total

at 31 March 2016 £000

Cost or valuation at 1 April 2015 10,924

Additions purchased 2,474

Reclassifications 3,299

Cost or valuation at 31 March 2016 16,697

Amortisation at 31 March 2015 4,027

Charged during the year 1,843

Amortisation at 31 March 2016 5,870

Net book value at 31 March 2016 10,827

Net book value at 1 April 2015 6,897

Purchased 10,827

Net book value at 31 March 2016 10,827

At 31 March 2015 £000

Cost or valuation at 1 April 2014 11,177

Additions purchased 357

Reclassifications 1,045

Disposals other than by sale (1,655)

Cost or valuation at 31 March 2015 10,924

Amortisation at 1 April 2014 4,483

Disposals other than by sale (1,655)

Charged during the year 1,199

Amortisation at 1 April 2015 4,027

Net Book Value at 1 April 2014 6,693

Purchased 6,897

Net book value at 1 April 2015 6,897

14.1 Economic lives Minimum Life Maximum Life

Years Years

Computer software - purchased 3 15


Page 28

15

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000

Total impairments and reversals charged to the statement of

comprehensive income 7,299 3,654

Total impairments and reversals charged to the revaluation reserve 4,779 2,341

Total Impairments 12,078 5,995

16 Commitments

16.1 Capital commitments

16.2 Other financial commitments

Group

accounts 31

March 2016

Group

accounts 31

March 2015

17 Inventories Drugs Consumables Total Total

£000 £000 £000 £000

Balance at 1st April 2015 739 139 878 823

Additions 18,469 2,410 20,879 17,175

Inventories recognised as an expense in the period (18,496) (1,865) (20,361) (17,120)

Balance at 31 March 2016 712 684 1,396 878

18 Trade and Other Receivables

Current Current Non-current Non-current

Group

accounts 31

March 2016

Group

accounts 31

March 2015

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000 £000 £000

NHS receivables - revenue 11,598 7,211 - -

NHS prepayments and accrued income 3,212 8,768 - -

Non-NHS receivables - revenue 1,992 - 315 258

Non-NHS prepayments and accrued income 1,884 1,750 - -

Provision for the impairment of receivables (1,051) (1,490) (69) (49)

VAT 535 751 - -

Other receivables 1,721 3,177 - -

Total 19,891 20,167 246 209

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000

Total Current and Non-current Receivables 20,137 20,376


Analysis of Impairments and Reversals

Capital commitments as at 31 March 2016 were £0.421m made up of improvements to the main Outpatients area, replacement

pipework, and work to lifts. (2014/15 £5.1m).

The Trust had no non-cancellable contracts (which are not leases or PFI contracts or other service concession arrangements) as at 31

March 2016.

Page 29

18.1 Ageing of impaired receivables

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000

Up to three months 31 207

Three to six months 35 151

By more than six months 810 1,181Total 876 1,539

18.2 Ageing of non-impaired receivables past their due date

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000

By up to three months 4,980 8,285

By three to six months 1,371 151

By more than six months 1,750 259Total 8,101 8,695

The Trust does not hold any collateral against receivables outstanding.

18.3 Provision for impairment of receivables

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000

Balance at 1 April 2015 1,539 806

Unused amounts reversed - 0

Amount written off during the year 0 110

(Increase)/decrease in receivables impaired (419) (843)Balance at 31 March 2016 1,120 1,539

19 Cash and Cash Equivalents

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000

Balance at 1 April 2015 9,667 11,932

Net change in year (2,513) (2,265)Balance at 31 March 2016 7,154 9,667

Made up of

Cash with Government Banking Services 3,973 5,725

Commercial banks 399 694

Charity cash held in commercial banks 2,782 3,248

Cash and cash equivalents as in statement of financial position 7,154 9,667Cash and cash equivalents as in statement of cash flows 7,154 9,667

20 Trade and Other Payables : Current

Group

accounts

Group

accounts

31st March

2016

31st March

2015

£000 £000

NHS payables - revenue 1,485 414

NHS accruals 2,553 2,294

Non-NHS trade payables - revenue 5,672 3,427

Non-NHS trade payables - capital 778 536

Non-NHS accruals 12,640 15,422

Social security costs 1,905 1,340

Tax 2,025 1,398

NHS charitable funds: Trade and other payables 9 471

Other 922 1,711

Total 27,989 27,013

27,989 27,013


Total Current Trade and Other Payables

Page 30

21 Borrowings

31st March

2016

Group accounts

31 March 2015

31st March

2016

Group accounts

31 March 2015

£000 £000 £000 £000

PFI liabilities

- Main liability 965 885 24,832 25,816

Capital loan from the Department of Health 540 - 9,460 3,350

Finance lease liabilities 155 61 131 388

Total 1,660 946 34,423 29,554

Total current and non-current 36,083 30,500

Capital loan

DoH Other Total

£000 £000 £000

Repayment of principal falling due in:

Within one year 540 1,120 1,660

Between one and two years 1,080 2,061 3,141

Between two and five years 2,160 3,860 6,020

After five years 6,220 19,042 25,262

Total 10,000 26,083 36,083

22 Finance Lease Obligations

22.1 Amounts payable under finance leases - Other:

Minimum lease

payments

Present value of

minimum lease

payments

31st March

2016

31st March 2016

£000 £000

Within one year 155 154

Between one and five years 131 130

After five years - -

Less future finance charges - -

Present value of minimum lease payments 286 284

Future minimum lease payments are calculated by adding the present value of minimum lease payments to the remaining

finance lease interest.

- An agreement with Netcall Telecom Limited for Telephony services. The agreement is for 5 years, commencing 31st

March 2015 and expiring in March 2020. The minimum payments under the lease total £99,900 payable over 5 years.

- An agreement with Asteral (MES) Limited for the Operation of a Healthcare (CT Scanning) Facility. The agreement is for

7 years, commencing in December 2010 and expiring in December 2017. The minimum payments under the agreement

total £996,000, payable over 7 years.

- A service agreement with Huntleigh Healthcare Limited for Bed Facilities Management. The agreement was for 10 years

and 3 months, commencing in January 2005 and expiring in March 2015. The minimum payments under the lease totalled

£1,020k payable over 10 years. Upon expiry, the contract was extended for a period of twelve months to 31st March 2016

at an annual cost of £87k.

During the year the Trust had three arrangements that are accounted for as finance leases under International Financial

Reporting Standards:


Current Non-current

Page 31

22.2 Finance Lease Obligations (continued)

23 Finance Lease Receivables

24 Private Finance Initiative Contracts

24.1

24.2


The Trust had no future sublease payments expected to be received as at 31 March 2016.

The Trust had no contingent rents recognised as an expense in the year.

The Trust had no finance lease receivables as at 31 March 2016.

Private Finance Initiative schemes off-Statement of Financial Position

The Trust did not have any Private Finance Initiative schemes that were excluded from the Statement of Financial Position as at 31

March 2016.

Private Finance Initiative schemes on-Statement of Financial Position

The Trust has entered into 2 Private Finance Initiative (PFI) agreements:

- A 29 year agreement for the Development of Phase 5 at Kingston Hospital and Provision of Services with Prime Care Solutions

(Kingston) Ltd ("Prime"), expiring in 2036; and,

- A 15 year agreement for the re-provision of Energy and Energy Management Services at Kingston Hospital with Veolia (formerly Dalkia)

Utilities Services PLC ("Dalkia"), expiring in 2023.

Under IFRIC 12 the assets of both schemes are treated as assets of the Trust. The substance of both agreements is that the Trust has a

finance lease and payments comprise of two elements, imputed finance lease charges and service charges.

24.2.1 Development of Phase 5 at Kingston Hospital and Provision of Services

- The Trust shall be entitled to terminate the agreement at any time on 6 months written notice to Prime.

There is a 2.5% RPI increase built into the providers financing model with a base date of 1 April 2002. Actual RPI is calculated on an

annual basis.

24.2.2 Energy and Energy Management Services

Veolia provide and maintain a combined heat and power plant to deliver heat and power to the Trust. Under IFRIC 12 the plant is treated

as an asset of the Trust. The Trust has the right to use the combined heat and power plant for the purposes specified in the project

agreement.

Under the PFI agreement Prime's obligation was to build the Kingston Surgical Centre building and car parking facilities at the Trust.

Under IFRIC 12 the Kingston Surgical Centre building is treated as an asset of the Trust. The Trust has the right to use the building for

the purposes specified in the project agreement and to receive the building at the end of the contract period.

The provision of services at the Trust by Prime include a car parking service, a catering service and all other soft facilities management

services across the Trust. Prime also provide a hard facilities management service to the Kingston Surgical Centre building.

Significant terms of the agreement include:

- Under clause 44.6 (replacement of non-performing sub-contractor) Prime will put forward proposals for the interim management of the

service.

- If Prime fail to provide relevant services to the Trust the Trust may perform such services itself or instruct a third party to do so. If

Prime then fail to terminate the relevant service the Trust shall be entitled to its option to exercise its rights in accordance with the

provisions of Clause 44.5 (remedy provisions).

- If in the circumstances referred to in Clause 43 (Force Majeure) the parties have failed to reach agreement on any modification to the

project agreement within 6 months of the date on which the party affected serves notice on the other party, either party may at any time

afterwards terminate the agreement by written notice.

Page 32

24

31st March

2016

Group accounts

31 March 2015

£000 £000

Within one year 4,126 4,038

15,539 15,755

After five years 72,361 77,211

Sub total 92,026 97,004

Less: interest element (66,229) (70,303)

Total 25,797 26,701

25 Charges to expenditure

26 The Trust is committed to the following charges for services:

31st March

2016

Group accounts

31 March 2015

£000 £000

Within one year 11,498 11,208Between one and five years 50,963 49,123After five years 253,035 265,432

Total 315,496 325,763

27 Deferred Income

31st March

2016

Group accounts

31 March 2015

£000 £000

Balance at 31 March 2015 2,414 2,887

Deferred income movement in year 253 (470)

Balance at 31 March 2016 2,667 2,417

Total current and non-current 2,667 2,417

- On the occurrence of a Veolia Event of Default referred to in clauses 35.1.3(b), 35.1.3 (c), 35.1.3 (d) and 35.1.7, the

Trust may serve notice giving Veolia the option to remedy the default within 20 business days, or put forward a reasonable

plan within 20 business days to remedy the default.


Private Finance Initiative Contracts (continued)

Veolia are obligated to provide the plant and machinery for the boiler house. On the expiry date of this contract the

funded new equipment shall vest in the Trust provided the Trust has paid Veolia any payment due to it under the project

agreement.

Significant terms of the agreement include:

- The party claiming relief under Force Majeure shall be relived of its liability under the project agreement to the extent

that by reason of the force majeure it is not able to perform its obligations under this Agreement provided that the Trust

shall continue to pay the Operating Element to Veolia notwithstanding the occurrence of an event of Force Majeure.

- On the occurrence of a Veolia Event of Default referred to in clauses 35.1.2, 35.1.3 (a), 35.1.4, 35.1.5, 35.1.6, 35.1.8

the Trust may terminate the agreement in its entirety by notice in writing having immediate effect.

The total charged in the year to expenditure in respect of the service element of on-statement of financial position PFI

contracts was £11.0m. Services include: car parking, catering, all other soft facilities management services across the

Trust and, provision of heat and power to the Trust.

- In the case of any Event of Default referred to in clause 35.1.7, if Veolia is awarded one or more warning notices in the

following contract month, the Trust can issue notice in writing which terminates the agreement with immediate effect.

- The Trust is entitled to terminate the project agreement any time on 6 months written notice to Veolia.

There is a 2.5% RPI built into the scheme with a base date of 1 September 2005. Actual RPI is calculated on an annual

basis.

24.3 On-SoFP PFI, LIFT or other service concession arrangement obligations

(finance lease element)

Between one and five years

The total charged in the year to expenditure in respect of off-statement of financial position PFI contracts was £NIL.

Page 33

28 Provisions

Pensions

relating to

former

directors

Pensions

relating to

other staff

Legal claims Redundancy Other Total

Group accounts 31st March 2016 £000 £000 £000 £000 £000 £000

At 1 April 2015 276 1,225 66 0 144 1,711

Arising during the year 0 0 37 0 19 56

Used during the year (19) (169) (31) 0 (97) (316)

Reversed unused 0 (49) 0 0 (59) (108)

Unwinding of discount 4 17 (1) 0 (2) 18

Change in discount rate 5 39 0 0 0 44

At 31 March 2016 266 1,063 71 - 5 1,405

Expected timing of cash flows:

Within one year 19 150 70 0 0 239

Between one and five years 61 533 0 0 0 594After five years 187 379 1 - 5 572

267 1,062 71 - 5 1,405


At 1 May 2014 267 1,284 103 91 1,607 3,352

Arising during the year - - 0 0

Used during the year (15) (138) (37) (47) 0 (238)

Reversed unused - - - (43) (1,463) (1,506)

Unwinding of discount 3 17 - - - 20

Change in discount rate 21 62 - - - 83

At 31 March 2015 276 1,225 66 0 144 1,711

Expected timing of cash flows:

Within one year 15 137 66 0 144 362

Between one and five years 262 1,087 - - - 1,349

After five years 0 0 - - - 0

277 1,224 66 0 144 1,711


Other provisions comprise Dilapidations (£5k). Pension payments are made quarterly and amounts are known. The pension provision is based

on life expectancy. Legal claims are calculated from the number of claims currently lodged with the NHS Litigation Authority and the probabilities

provided. It is also included in the provisions of the NHS Litigation Authority at 31 March 2016 in respect of clinical negligence liabilities of the

Trust.Page 34


29 Contingencies

29.1 Contingent liabilities

31st March

2016

Group accounts

31 March 2015

£000 £000

Liability to Third Parties Schemes (LTPS) 33 29

Total 33 29

29.2 Contingent assets

30 Financial Instruments

30.1 Financial assets Loans and

receivables

Total

£000 £000

Trade and other receivables 18,051 18,051

Cash and cash equivalents 4,372 4,372

Total at 31 March 2016 22,423 22,423

Loans and

receivables

Total

£000 £000

Trade and other receivables 18,944 18,944

Cash and cash equivalents 9,667 9,667

Total at 31 March 2015 28,611 28,611

30.2 Financial liabilities At fair value

through profit

and loss

Other Total

£000 £000 £000

Trade and other payables 24,003 24,003

PFI and finance lease obligations 36,083 - 36,083

Total at 31 March 2016 36,083 24,003 60,086

At fair value

through profit

and loss

Other Total

£000 £000 £000

Trade and other payables 24,275 24,275

PFI and finance lease obligations 30,500 - 30,500

Total at 31 March 2015 30,500 24,275 54,775

The Trust had no contingent assets at 31 March 2016.

Page 35

30 Financial Instruments (continued)

30.3 Financial risk management

International Financial Reporting Standard 7 requires disclosure of the role that financial instruments have had during

the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing

service provider relationship that the Trust has with clinical commissioning groups and the way those clinical

commissioning groups are financed, the Trust is not exposed to the degree of financial risk faced by business

entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of

listed companies, to which the financial reporting standards mainly apply. The Trust has limited powers to borrow or

invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than

being held to change the risks facing the Trust in undertaking its activities.

The Trust’s treasury management operations are carried out by the finance department, within parameters defined

formally within the trust’s standing financial instructions and policies agreed by the board of directors. Trust treasury

activity is subject to review by the Trust’s internal auditors.

30.3.1 Currency risk

The Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in

the UK and sterling based. The Trust has no overseas operations. The Trust therefore has low exposure to currency

rate fluctuations.

30.3.2 Interest rate risk

The Trust borrows from government for capital expenditure, subject to affordability as confirmed by the London

Strategic Health Authority. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and

interest is charged at the National Loans Fund rate, fixed for the life of the loan. The Trust therefore has low

exposure to interest rate fluctuations.

30.3.3 Credit risk

Because the majority of the Trust’s income comes from contracts with other public sector bodies, the Trust has low

exposure to credit risk. The maximum exposures as at 31 March 2015 are in receivables from customers, as

disclosed in the trade and other receivables note.

30.3.4 Liquidity risk

The Trust’s operating costs are incurred under contracts with clinical commissioning groups, which are financed from

resources voted annually by Parliament. The Trust also has access to a £6m working capital facility to help mitigate

potential liquidity risks that may be associated with the current level of financial challenge facing the NHS.

31 Events after the Reporting Period

The Trust has finalised its Operational Plan for 2016/17 and has set a surplus budget of £3.922m for the year to 31

March 2017, conditional on receipt of £8.1m Sustainability Transformation Funding.

The Trust has a working capital facility of £6m available from Lloyds Bank in 2016/17 .

32 Losses and Special Payments

There were 37 cases of losses and special payments totalling £66,000 accrued during 2015-16 but excluding

provisions for future losses

33 Related Party Transactions

During the year none of the Department of Health Ministers, Trust Board members or members of the key

management staff, or parties related to any of them, has undertaken any material transactions with the Trust.

All interests are properly registered in the Trust's Register of Interests.


As such the Trust will remain as a Going Concern as per IAS1.

Page 36

33 Related Party Transactions (continued)

Payments to

Related Party

Receipts from

Related Party

Amounts

owed to

Related Party

Amounts due

from Related

PartyGroup accounts 31 March 2016 £000 £000 £000 £000

Department of Health - - - 126

Epsom and St Helier University Hospitals NHS Trust 252 1,339 192 972

Health Education England 78 8,589 508 49

Hounslow and Richmond Community Healthcare NHS Trust 193 109 262 71

Kings College Hospital NHS Foundation Trust 448 59 161 19

Merton Borough Council 125 273 125 53

NHS Blood and Transplant 1,025 16 63 -

NHS England - 15,798 21 1,100

NHS Hounslow CCG - 1,369 - 222

NHS Kingston CCG - 79,703 792 2,031

NHS Litigation Authority 4,763 185 184 2

NHS Merton CCG - 10,316 208 323

NHS North West Surrey CCG - 1,697 31 96

NHS Richmond CCG - 43,045 474 3,080

NHS Surrey Downs CCG - 27,965 218 1,166

NHS Sutton CCG - 1,245 89 -

NHS Wandsworth - 14,867 167 949

Royal Borough of Kingston Upon Thames 1,389 2,414 185 96

South West London and St George's Mental Health NHS

Trust 406 149 76 12

St George's University Hospitals NHS Foundation Trust 9,739 8,227 2,439 2,041

Surrey County Council - 832 16 4

The Royal Marsden NHS Foundation Trust 314 1,259 314 796

34 Intra-government and other balances Current

receivables

Non-current

receivables

Current

payables

Non-current

payables

£000 £000 £000 £000

Balances with Other Central Government Bodies 639 - 3,993 -

Balances with CCG's and NHS England 10,208 - 69 -

Balances with Department of Health 126 - 297 -

Balances with Health Education, Public Health England and

Special Health Authorities

51-

3-

Balances with Local Authorities 625 - 303 -

Balances with bodies outside the Departmental Group 0 - 0 -

Balances with NHS Trusts and Foundation Trusts 4,379 - 3,969 -

Balances with non-Departmental Public Bodies 1 5

Balances with other Department of Health bodies 0 53

Balances with Public Corporations & Trading Funds 0 - 0 -

Balances with bodies external to government 3,842 246 19,236 -

Balance at 31 March 2016 19,871 246 27,928 -

Balances with Other Central Government Bodies 833 - 4,528 -

Balances with CCG's and NHS England 11,314 - 65 -

Balances with Department of Health 52 - - -

Balances with Health Education, Public Health England and

Special Health Authorities

26

-

90

-

Balances with Local Authorities 351 - 89 -

Balances with bodies outside the Departmental Group 0 - - -

Balances with NHS Trusts and Foundation Trusts 4,646 - 2,678 -

Balances with Public Corporations & Trading Funds - - - -

Balances with bodies external to government 2,944 - 19,563 -

Balance at 31 March 2015 20,166 - 27,013 -


In addition, the Trust has a number of balances at year end with other government departments and other central and local

government bodies. Most of these transactions have been with HM Revenue & Customs in respect of PAYE, NI contributions and

VAT refunds.

The Trust received capital contributions from Kingston Hospital NHS Trust General Charitable Fund (Registered Charity Number:

1056510), the corporate trustee for which is the Trust Board. The audited accounts of the Fund are available on the Charity

Commission website.

The Department of Health, as the parent of Kingston Hospital NHS Foundation Trust, is regarded as a related party. During the year

the Foundation Trust has had a significant number of material transactions with the other entities listed below for which the

Department of Health is regarded as the parent. Also included are local government bodies where material transactions have taken

place.

Page 37


35 Third Party Assets

36 IFRIC 12 Adjustment

Group

accounts 31

March 2016

Group

accounts 31

March 2015

£000 £000

36.1

Depreciation charges 552 637

Interest expense 3,284 3,196

Other expenditure 11,055 11,027

Impact on Public Dividend Capital dividend payable 657 806

Total IFRS expenditure (IFRIC 12) 15,548 15,666

(15,243) (14,871)

Net IFRS change (IFRIC 12) 305 795

The Trust held no cash and cash equivalents at 31 March 2016 which relates to monies held by the Trust on behalf of

patients.

Revenue consequences of IFRS: Arrangements reported on the

statement of financial position under IFRIC 12 (e.g. private finance

initiative)

Revenue consequences of PFI schemes under UK GAAP (net of any sub-

leasing income)

Page 38


37 Charitable Funds

Endowment

Reserve

Unrestricted

Funds

Restricted

Funds Total

£000 £000 £000 £000

Opening balance 1 April 2015 57 311 2,456 2,824

Surplus/ (Deficit) for the year - (58) 84 26

Closing balance 31 March 2016 57 253 2,540 2,850

37.1 Name of fund

Permanent endowment funds

V A W Holton – Research

Restricted funds

Born Too Soon

Cancer Research

Cancer Unit Appeal

Cancer Unit Maintenance

I C Lewis – Nursing Research

Mrs A B Grubb – Research

Orthopaedic Equipment

Urology Equipment

V A W Holton – Research

Unrestricted funds

Description of the nature and purpose of each

Capital to be held in perpetuity. Income to be used

for any research activity undertaken by the Hospital

To be used for any charitable purpose or purposes to

provide facilities for treatment of premature babies

To be used for research into cancer

To be used for the relief of sickness by the provision

of a new cancer unit at Kingston Hospital NHS Trust

and the upkeep and maintenance of this unit

Income derived from the permanent endowment to

be used for any research activity undertaken by the

Hospital

To be used to purchase urology equipment

Capital and income to be used for research

purposes

To be used to purchase orthopaedic equipment

To provide bursaries for awards to encourage

research and training by nurses

To be used to fund ongoing maintenance of the Sir

William Rouse Cancer Unit

The unrestricted funds are available to be spent for

any of the purposes of the charity

Page 39

Audit risk How we responded to the risk

to estimate accruals of expenditure for amounts not invoiced at the year end. We identified completeness of expenditure on goods and services as a risk which requires particular audit consideration.

the associated controls;

• testing, on a sample basis, post year-end payments to confirm the completeness of liabilities and accruals;

• reviewing management's process for recognising provisions; • and • considering the completeness of reported accruals and

provisions by review of Trust committee minutes and events subsequent to the year end .

The group's accounting policy on expenditure on goods and services is shown in note 1.7 to the financial statements and related disclosures are included in note 7.

Valuation of property, plant and equipment

The Trust has an asset base of £133,551,000 of which 90% relates to land and buildings used by the Trust to deliver its services. The valuation of property, plant and equipment involves estimates that require significant judgements. We therefore identified the valuation of property, plant and equipment as a risk which requires particular audit consideration.

Our audit work included, but was not restricted to:

• obtaining management's assessment of the valuation of

property, plant and equipment and understanding the

valuation process including the design of key controls

and significant assumptions;

• challenging and obtaining corroborative evidence of the

assumptions made by management in relation to:

o the valuation of property, plant and equipment;

and

o the useful economic lives of property, plant and

equipment and the resulting amount of

depreciation charged in the year

o

• reviewing the competence, expertise and objectivity of management's valuer;

• reviewing instructions issued to the valuer and the scope of their work, including the completeness of the data provided to the valuer; and

• testing, on a sample basis, revaluations made by the valuer are input correctly into the Trust's asset register.

The group's accounting policy on property plant and equipment is shown in note 1.8 to the financial statements and related disclosures are included in note 13.

Our application of materiality and an overview of the scope of our audit

Materiality We define materiality as the magnitude of misstatement in the financial statements that makes it probable that the economic decisions of a reasonably knowledgeable person would be changed or influenced. We use materiality in determining the nature, timing and extent of our audit work and in evaluating the results of that work. We determined materiality for the audit of the group financial statements as a whole to be £4,465,000 which is 2% of the group's gross operating costs. This benchmark is considered the most appropriate because we consider users of the group's financial statements to be most interested in how it has expended its revenue and other funding.

annual report and accounts 2015-16 · in 2015-16 the trust saw an 8.7% increase in referrals from...

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