Annual Report and Accounts - Surrey and Borders Partnership NHS ...

Surrey and Borders Partnership
NHS Foundation Trust
Annual Report
and Accounts
1 April 2010 –
31 March 2011

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Surrey and Borders Partnership NHS Foundation Trust
Annual Report and Accounts
1 April 2010 – 31 March 2011
Presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the
National Health Services Act 2006
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Contents
An introduction to the Trust 6
Foreword by the Chairman and Chief Executive 7
Directors’ Report and Management Commentary 9
Operating and Financial Review 33
Quality Report 39
Corporate Governance and Board of Directors 69
Council of Governors 76
Membership 79
Remuneration Report 81
Annual Accounts 85
Ladan Saghari, Volunteer of the Year
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An Introduction to the Trust
We provide specialist mental health, learning disability and drug
and alcohol services for people of all ages in Surrey and North
East Hampshire.
Our services span 77 sites and include mental health care in HMP Send, Highdown and
Downview; residential social care services for people with a learning disability in Croydon;
supported living social care services in Hampshire; and forensic drug and alcohol services
on the Hampshire coast.
We have a workforce of 2,814 people. Many of these are highly-skilled professionals who
work with a variety of partners in the private, public and voluntary sectors to ensure we
deliver high quality care to our local population of 1.3 million. We seek to involve and
engage people who use our services in our community and we have around 5,000 public
members of our Foundation Trust.
We were established as a health and social care partnership trust in April 2005 and
became an NHS Foundation Trust in May 2008 - the first mental health and learning
disability trust in the South East Coast NHS region to gain this status.
Our overall income for the 2010/11 financial year was £170 million.
Our core purpose is “To deliver
excellent and responsive assessment,
treatment and care, focused on the
needs and contributions of the
individual; and to lead our
communities in challenging stigma
and improving the mental health and
well-being of people living within our
communities.”
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Foreword by the Chairman and
Chief Executive
Our third year as a Foundation Trust has been a year of great change where we have
continued to improve the quality of our services whilst finding more efficient ways of
working and reducing costs. This year we have developed further as a strong and
successful organisation in this challenging period for the public sector.
We ended the last financial year with two conditions placed on our registration by the Care
Quality Commission (CQC) and this has become a real success story. Much work was done
between April and October to change practices and evidence improved standards in order
to gain us full registration. The scale of this turnaround was recognised by our local CQC
commissioner recently who rated the changes as being ‘among the best in the country’
before inviting us to publish a paper on what we did to change things so thoroughly and
quickly to help inform other trusts struggling in this area.
We have been one of the first trusts in the country to launch a new county-wide acute
liaison nurse service to help ensure that having a learning disability isn’t a barrier to people
getting the care they need in local general hospitals.
We were the first trust in the NHS South East Coast region to successfully roll-out RiO, the
single electronic patient records system, across our services. RiO enables clinicians to have
immediate access to patient files, making our services much more responsive to individual
need.
Our modern hospital development at Farnham Road Hospital was granted planning
permission from the local authority. Our project team was commended by the borough
council on the detail of their plans – which was only possible thanks to feedback received
in an ongoing public engagement programme with our local communities. We now plan to
start the construction phase of this project in summer 2012.
The year-end sees the seven-year Social Care Change Programme drawing to a close too.
This is part of a national trend for residential care to no longer be provided by the NHS and
we have worked with commissioners to transfer services to independent care providers.
Members of our Council of Governors have just reached the end of their first three-year
term of office and Trust members have elected their representatives to contribute to the
Trust’s development over the next term. We would like to extend our gratitude to those
out-going Governors for their commitment to their role and their input into the Trust’s
development, which has given us a strong basis to build on.
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Richard Greenhalgh joined the Trust in February 2011 as Chairman and we extend our
thanks to Roshan Bailey, our Deputy Chairman, who fulfilled the role of Interim Chairman
after Graham Cawsey’s departure in July.
We’ve had to make a number of difficult decisions too. Until this year we hadn’t enforced
the statutory retirement age of 65 years. But in the face of probable job losses due to
service reductions we took the difficult decision to do so. Sadly it means we had to say
goodbye to many people who will be greatly missed by friends and colleagues and this was
not a decision we took lightly. As the number of sites we operate from has decreased in
recent years from nearly 130 in 2005 to 77 today, we are now re-structuring our corporate
teams to ensure these are as efficient as possible.
It is a real credit to the dedication of our staff and to the leadership of our Board, that
despite the ongoing pressures, efforts to improve the experience of staff and people who
use our services has been reflected well in our CQC national survey findings. Our overall
score in the 2010 Community Mental Health Survey was the highest of mental health
trusts in the South East Coast Region and we received some of the highest scores in the
country for involving individuals, and their friends and relatives, in decisions about their
care. In the NHS Staff Survey we were ranked in the top 20 percent of mental health trusts
for staff feeling motivated about their jobs and satisfied with the quality of work and
patient care they are able to deliver.
That leads us to offer our dedicated staff a special thank you for not only adapting to these
changes but for contributing their skill and expertise to help us develop new ways of
working and build better services. We thank them for their continued commitment to
improving the lives of people in our local communities. We would also like to extend our
gratitude to the many partners that we work with across the statutory and voluntary
sectors. Together this close partnership working enables the individuals we serve to
receive comprehensive treatment, support and care.
Richard Greenhalgh
Chairman
Fiona Edwards
Chief Executive
Richard Greenhalgh, Chairman
Fiona Edwards, Chief Executive
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Directors’ Report and
Management Commentary
Services Provided by the Trust
The Trust provides a range of specialist health and social care and treatment through its
community, hospital, rehabilitation and residential services. These are provided to the
following communities:
Services Surrey North East
Hampshire
Adult learning disabilities
Children and young persons learning disabilities
Working age adult mental health
Older persons mental health
Children and young persons mental health
Forensic mental health
Prison in-reach mental health
Eating disorders
Drug and alcohol
The services we provide aim to:
■ Create blended health and social care services which work together to provide
integrated mental and physical health and social care support to vulnerable people,
their families and carers and promote their recovery
■ Deliver person-centred services which help people with long term conditions to
choose how to manage their condition well, ensure equal access to care for all,
based on people’s individual needs and preferences
■ Contribute our expertise to multi-agency care pathways which work well for
individuals and make sure they receive the right support from the right service at
the right point to maximise their benefit and optimise outcomes
■ Offer a range of services from acute specialist inpatient and crisis care, for those
who are most unwell, through to short focused interventions for people needing
support to manage adverse life events; and consultancy and facilitation, in
partnership with other agencies, to enable people to remain at work or engaged in
other home and community based activities, not necessarily provided by us
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Board of Directors
The Directors of the Trust for the reporting period were:
Non Executive Directors
■ Graham Cawsey, Chairman (until 13 July 2010) 1
■ Richard Greenhalgh, Chairman (from 16 February 2011)
■ Roshan Bailey
■ John Banfield
■ Della Fallon
■ Peter Harrison
■ Barry Rourke
■ Richard Vause
Executive Directors
■ Fiona Edwards, Chief Executive
■ Clive Field, Director of Finance (from 1 July 2010) 2
■ Rachel Hennessy, Medical Director 3
■ Pat Keeling, Director of Strategic Change 4
■ Mandy Stevens, Director of Quality and Performance (Nurse Director)
■ Jo Young, Director of Operations
1 Roshan Bailey was appointed Interim Chairman for the period 14 July 2010 until 15 February 2011
2 Alison McKay was appointed Interim Director of Finance for the period 1 March 2010 – 27 May 2010;
Ann Harrison was appointed Interim Director of Finance for the period 28 May 2010 – 30 June 2010
3 Rachel Hennessy was Interim Medical Director for the period 1 March 2010 until 28 February 2011
4 Pat Keeling was appointed Board voting rights from 30 June 2010
Jos Sartain, Employee of the Year
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Service Developments
We have made a number of service developments over the past year, in conjunction with
our NHS and county council commissioners. They are part of an ongoing programme of
improvements and a summary is included below along with our plans for the coming year.
Mental Health Services
Adult Community Services
We have restructured our 17 Community Mental Health Teams (CMHT) for adults of
working age, following a consultation with staff, to form 11 Community Mental Health
Recovery Services. It followed a fundamental change to the services we provide with the
national introduction of Improving Access to Psychological Therapies. In Surrey our adult
Community Mental Health Services are now commissioned to provide secondary care
services for people with severe and/or enduring symptoms.
As part of this commissioning change we conducted a detailed review of the way our
CMHTs were organised, using national benchmarking data and independent reports, which
recommended changes to reflect the smaller case load and to create a more equitable
service across Surrey - something that had not been fully addressed since our predecessor
Trusts merged in 2005.
In December the Trust and Surrey County Council signed a formal Section 75 agreement to
provide fully integrated health and social care to people who use our services and their
carers. The agreement enables both health and social workers to assess the needs of
carers. An agreed pathway and procedure has been developed to ensure assessments are
carried out consistently and six new carer liaison workers have been recruited by Surrey
County Council to provide carers with additional support.
Since the launch of the Trust’s mental health crisis helpline for people in distress in April
2009 the service has been well received with the average number of calls now reaching
1,000 a month. An audit of the service has been undertaken by commissioners to establish
where improvements can be made to this important service and an action plan will be
developed for Summer 2011.
Older People’s Services
Our clinicians worked very closely with NHS Surrey during the reporting year to develop a
new proposal for how local mental health services for older people should be organised.
The public consultation launched in July and ran until October 2010. Our clinicians also led
a successful bid for additional funding for the developments, specifically around dementia
care, which was submitted to the NHS South East Coast Transformation Fund. The strategy
began to be implemented in February 2011 with memory clinics now being run in each
borough and local implementation groups are now in place with key stakeholders
responsible for making the proposals happen. We have already provided training in
dementia care to staff working in Surrey’s five general hospitals.
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We have made a number of changes to our Community Mental Health Teams for older
people to improve the care pathway for people using these services and ensure better
communication between health and social care services staff. One key development is the
integration of social care staff on each team to mirror adult mental health services. The
referral pathway has also changed to ensure a much more team-based approach to
developing care packages. New referrals are now discussed by the whole multi-disciplinary
team at regular meetings to ensure that people receive a comprehensive and appropriate
care package. We worked closely with the Alzheimer’s Society to achieve this, working on a
three-way agreement to ensure the new structure serves the best interests of people using
our service.
Trust services were named as one of ten case studies in a much publicised report from the
Health Service Ombudsman. The reported entitled “Care and Compassion” detailed cases
from across the UK where the care of elderly patients had fallen below that which was
expected. Detailed action plans relating to the incident which occurred some six years ago
had been previously drawn up and implemented. Since publication of the report, our
quality and risk managers have examined each of the ten cases and conducted a close
study of our older people’s services and additional actions required to improve the
standard of care provided have been highlighted for implementation.
Inpatient Services
Planning permission was granted to build a modern two storey building, with new therapy
spaces and four new wards, at Farnham Road Hospital in Guildford. The new development
will include a psychiatric intensive care ward along with a Section 136 suite for people
brought by police to a place of safety. Building work is set to commence in Summer 2012
and adult inpatient services will be relocated to the Abraham Cowley Unit in Chertsey and
the Ridgewood Centre in Frimley for approximately two years whilst demolition and
building work is taking place.
In our older adult inpatient services, Hayworth House has been re-furbished to make it
easier for people who have dementia to manage and Willow Ward now offers end-of-life
care as well as continuing care services.
Five team leaders have been appointed to support the development of mental health
services within Surrey’s five general hospitals over the next year. They will work with
existing liaison teams and psychology colleagues there to understand where there are gaps
in the liaison service - which supports people with mental health problems who access
accident and emergency or who are ward patients. We have established professional
groups in each hospital to discuss clinical issues and are inviting partners such as the
police; ambulance service and social care services to help us improve care pathways.
The two adult mental health hospital wards in Epsom were awarded a ‘Good’ rating in the
2010/11 Accreditation for Inpatient Mental Health Services (AIMS) scheme developed by
the Royal College of Psychiatrists. Staff were required to work through 142 standards
encompassing admission, safety and therapies as part of their plans to make a meaningful
difference to those that receive care on the wards as well as supporting implementation of
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NICE guidance. Next year the unit will also be working towards accreditation for the
psychiatric intensive care unit.
Children and Young People’s Services
Child and Adolescent Mental Health (CAMHS) staff are currently being trained in a new
clinical system - the Choice and Partnership Approach - which has been implemented to
help improve the experience of people using the service, increase accessibility and staff
satisfaction, and reduce waiting times. It involves introducing an initial 45 minute choice
assessment ahead of the usual one and a half hour full assessment to enable people using
the service to be prioritised, and for those who could be better served by other teams to
be signposted to these services.
Following the withdrawal of voluntary sector counselling services a new post-sexual abuse
senior practitioner role has been created with funding from Surrey County Council and
NHS Surrey, which is being managed as part of the Trust’s Children and Young People’s
Service.
Looking ahead to the coming year, adult Eating Disorder Services will be integrated into
the Children and Young Persons Service to help ease the transition for adolescents with the
condition. This will see the launch of the Trust’s first ageless service right across Surrey.
Funding has been granted to continue the Targeted Mental Health in Schools programme
in Redhill, Reigate and Merstham over the next financial year. The successful programme
has offered mental health awareness training to school staff alongside support from
mental health workers who provide earlier intervention and access to treatment.
Lee Butler, Support Worker of the Year runner-up
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Learning Disability Services
In recognition of the fact people with learning disabilities are living much longer and fuller
lives than ever before, we have pioneered a number of schemes aimed at supporting
individuals to access services and make independent, informed decisions about their
healthcare and lifestyle:
■ A new six-week nutrition course run by our dieticians is enabling support workers to
help people make healthier food choices
■ Our psychology lead has worked with the National Transplant Service to produce
the country’s first official easy-read leaflet about organ donation and to help people
with a learning disability to make end of life care decisions
■ We have launched a new hospital liaison service for people with learning
disabilities. Three specialist nurses were recruited to support people with a learning
disability when they go to one of Surrey’s district general hospitals. This will help
ensure that having a learning disability does not become a barrier to getting
treatment
■ To support the new service, our teams have developed a set of easy-read materials
to help people with a learning disability communicate their needs in hospital. They
include a Hospital Passport, a record of essential information about their health; a
Hospital Communication Book, to help hospital staff communicate with people; and
a questionnaire to give people the chance to feedback on their visit and help
clinicians improve their services. These are now being used nationwide
■ We are currently recruiting specialist nurses to support people in prison who have a
learning disability and they are expected to be in place next year
In our learning disability residential services, the Social Care Change Programme has
continued to progress with the majority of services now transferred to independent
providers. This is part of national policy to move social care services out of the NHS and
give people who have a learning disability more independent lifestyles.
In our healthcare homes the NHS Campus project, also in line with national policy, is
reaching its final stages. It has involved finding more modern accommodation outside the
NHS for people living in clusters - or campuses - of group homes. Both the Social Care
Change Programme and the NHS Campus project are due to be concluded in the first part
of 2011/12.
At the start of the new financial year we will also be submitting planning permission to
build a new residential healthcare unit for people with learning disabilities in East Surrey to
replace existing accommodation on the Oaklands site in Caterham. The new unit is
expected to accommodate eight individuals who have been closely involved in the design
of their new home.
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Specialist Services
Good progress has been made across the Trust’s specialist services this year with all
services performing well against their expected targets. Particular highlights for each
service are listed below.
Drug and Alcohol
Existing Drug and Alcohol Services are performing well against targets for providing a good
standard of health and social care support and the number of people retained for the
duration of their treatment. During the year, services to North East Hampshire were
commissioned to an alternative provider and we now supply services across Surrey and in
Portsmouth.
The Drug and Alcohol Service has built strong links with local Nepalese residents, a
traditionally hard-to-reach community, and has increased the number of Nepalese
individuals accessing services. The success came from reaching out to this audience by
organising events in a local community setting and producing Nepalese resources about
the services available.
In the coming year the Drug and Alcohol Service is introducing a new tool in conjunction
with the Drug and Alcohol Action Team known as ITEP (International Treatment
Efficiencies Project). This is designed to get people more involved in planning their own
care through adopting psychosocial interventions. Staff will also be working with NHS
Surrey and the Drug and Alcohol Action Team to develop a more recovery-focused model
of care in the coming year.
Eating Disorders
The Eating Disorder Service is performing well against targets and will be transferring to
the Children and Young People’s directorate in the new financial year. The majority of
people using this service are aged between 18 and 35 so there will be a focus on
developing services suitable for this age group, to mirror the success of the Early
Intervention in Psychosis Service. Adults with eating disorders will be treated under this
service too.
New developments include a ‘step-down group’ to assist people progressing from using
day services into community-based support and a more widespread and improved use of
Mentalisation Based Therapy alongside Cognitive Behavioural Therapy. These therapies
help people gain insight into how their behaviour and feelings are associated with specific
mental states and equip them with skills to help regulate their emotions.
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Forensic Services
This year has seen some changes to the way in which the Community Forensic Service is
resourced, which has provided an opportunity to redesign the service profile to move
towards a single service for Surrey. The service has been working with MAPPA (Multi-
Agency Public Protection Arrangements) to provide a link with the Trust and to devise
bespoke management plans to increase public safety. High praise has been received from
MAPPA regarding our good work.
Strong links have also been developed with Sussex Partnership NHS FoundationTrust
Forensic Services, which have been useful in facilitating cross-service assistance in carrying
out particular assessments. For example the Sussex Forensic Service has provided an
independent rating of our work in assessing psychopathic behaviour to ensure robustness
of our assessments. The service has also signed joint transport and information sharing
protocols with Hampshire Partnership NHS Foundation Trust.
Prison Mental Health Services
The past year has been a good one for the Prison Mental Health Services with targets being
met. The annual report from HMP Send’s Independent Monitoring Board states that
mental health staff have worked hard to meet the complex health needs of inmates. A new
weekly mental health drop-in clinic has been set up to encourage inmates to get help
early-on and a short eight-week course is being piloted where inmates openly discuss
topics such as how they can handle self-harm or the benefits of exercise.
We are working with our commissioners to explore how services can be expanded to
provide more support to inmates across Surrey’s prisons including specific services for
those with a learning disability.
Specialist Therapies
The Specialist Psychology Service has been reconfigured as part of the adult community
mental health services redesign programme and is now being delivered within the new
Community Mental Health Recovery Services. Neuropsychology Assessment Services are
being retained as a specialist service and will now be extended from west Surrey and north
east Hampshire to serve the whole Trust. The Community Health Psychology Service has
built on its successful development of practice within the multi-disciplinary teams,
providing care for people with complex needs including chronic pain, diabetes and anorectal
problems, and now has contracts to provide services for people with cancer,
stroke/neurology and audiology problems.
The Family Therapy Service will continue to provide highly specialised direct client services
and will expand the consultation and outreach components to community and inpatient
services to assist in building a ‘Think Families’ approach.
In the year ahead, the Psychotherapy Service will be reconfigured with an emphasis on
providing Trust-wide recovery-focused treatment and support for people with a
personality disorder.
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Corporate Services
The Trust has undertaken a review and transformation of its corporate services during
2010/11 to reduce back office costs to bring us more in line with similar NHS organisations.
The reduction in the number of Trust owned sites and the ongoing introduction of
improved IT systems have both attributed to this reduction. Work will continue in the
coming year to ensure that these teams are working efficiently, offering good value for
money and that a minimal amount of the Trust’s income is attributed to corporate
functions.
As part of this process we will be consolidating the majority of our corporate staff into a
single location with around 140 staff moving to our Trust headquarters in Leatherhead in
Summer 2011.
Health and Safety
Membership of the Trust’s Health and Safety Committee has been widened this year to
reflect the extended remit of the Health and Safety department. We have seen an
improved attendance on the Trust’s health and safety training courses which has been
reflected in improved results within the 2010 NHS Staff Survey. Proposals for holding all
areas of the Trust to account for their compliance with statutory requirements are in hand
for the coming year, which will include enhanced internal audits.
The Occupational Health department has been working with colleagues in Human
Resources to improve the health and well-being of staff. This has included both local and
national well-being initiatives and the Trust has organised a number of events such as
sponsored walks and sports days for both staff and people who use services and carers.
In advance of the introduction of an accreditation scheme “Safe Effective Quality
Occupational Health Service” being introduced next year, all occupational health protocols
are being revised prior to submitting our application.
Countering Fraud and Corruption
The Trust is committed to countering fraud and corruption and encourages a culture of
honesty and transparency within the organisation and to the rigorous investigation of any
identified cases.
The Trust is fully supportive of counter fraud work and ensures that it is measured against
the criteria defined by the Secretary of State Directions to NHS bodies on Counter Fraud
measures. Emphasis is placed on creating a strong anti-fraud culture to ensure that the
organisation and its resources are protected. The work at the Trust, which is contracted to
South Coast Audit, is reviewed annually by the Counter Fraud and Security Management
Service. The 2009/10 assessment issued in February 2011 rated the Trust as performing
strongly with evidence of innovation and notable practice and awarded the maximum
score of four.
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From April 2011, the Counter Fraud and Security Management Service will become part of
NHS Protect and some of the work previously carried out by the regional teams will
become part of the local counter fraud specialists’ remit. This will increase the work to be
carried out locally. In addition, a priority for 2011/12 is to ensure that adequate processes
are in place in line with new legislation for example the Bribery Act 2010 which comes into
operation in July 2011.
Enabling Programmes
The Trust successfully completed the installation of its RiO clinical record project during
2010. From September 2010 all services apart from Drug and Alcohol and Learning
Disability Social Care Services have been using a single care records system. This has
provided improvements in communication of care plans and assessments for both people
who use services and carers. It has also led to better reporting and tracking of Mental
Health Act compliance, outcomes reporting and data quality. The project is now focused
on benefits realisation and cost improvements in back office functions. The RiO system has
also enabled staff to begin to work remotely with an accessible care record. A number of
consultants can now access RiO in GP surgeries and other premises.
Greater availability of remote working has also been a theme for operational and
corporate services and this has enabled the Trust to have greater resilience and improved
business continuity at times when weather has adversely impacted on travel
arrangements. We were therefore able to maintain all core services during two episodes of
heavy snow.
We have also focused on driving through the benefits of our considerable investment in IT
which has led to improvements in the use of IT with less reliance on paper processes and
administrative support. These initiatives are all focused on enabling better quality, safe
care and treatment for vulnerable people.
Environmental Modernisation Team, Team of the Year runner-up
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Trust Buildings and Environmental Matters
The Trust Estates Strategy sets out a significant transformation programme over the next
five years for our built environment, which will improve the quality of experience for
people who use services, carers and families, visitors and staff.
The Trust has now reduced its estate to 77 sites, from 127 sites in 2005, through a planned
programme to dispose of inappropriate premises which gives a gross floor space of just
under 116,000 square metres. 24-hour care environments and community team bases
continue to be improved through refurbishment programmes and leasing of new buildings
including the Aldershot Centre for Health which is an important new site added to the
portfolio for community services in North East Hampshire.
Over the next year, the Estates Strategy will continue to be implemented to enable the
realisation of the new hospital development and to improve our community environments.
In particular, a new single base for Adult and Older Adult Community Mental Health Teams
will be established in Waverley in June 2011 to improve safety for staff and access to
services. In other areas the disposal of several sites will be concluded, which will have a
significant impact on the shape of the estate, and we expect to finish 2011/12 with around
16 percent less floor space.
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Sustainability
It is now widely recognised that climate change is a serious threat to life, our health and
our wellbeing. In this context and with increasingly stringent carbon reduction targets,
financial pressures and social responsibility there is a clear and strong case for taking
action to manage carbon emissions.
We recognise the importance of managing the environmental impact of our operations
and our work with the Carbon Trust in 2009/10 helped us to create a systematic analysis of
our carbon footprint. A structured Carbon Management Plan and supporting action plan
has been developed for realising carbon savings and embedding best practice in the
organisation’s day-to-day operations. This commits the Trust to a target of reducing CO 2 by
18 percent by 2013, compared to recorded data in 2007/08, and underpins potential
financial savings to the organisation of around £576,000 per year by that date.
Over the last 12 months we have actively progressed our estates rationalisation
programme to:
■ Eliminate poor energy performing buildings by moving staff and services into
buildings with improved environments and energy performance
■ Deliver a programme of boiler replacement, loft and wall insulation installation
■ Improve boiler and heating controls across our estate to reduce energy
consumption and improve the working environment in many buildings
The Trust’s Environmental Strategy Group meets regularly to monitor the progress and
actions against the Trust’s Carbon Management Plan. Periodical updates are also provided
to the Trust Board to ensure Directors are apprised of progress. Currently we are is still on
track to meet our target 18 percent reduction in carbon emissions over and above our
estates rationalisation by 2013.
Future Priorities and Targets
We are maintaining our commitment to the following priorities for carbon management:
■ Maintaining a management and performance monitoring structure to ensure the
plan is delivered by utilising the current Environmental Strategy Group, which
continues to be responsible for the implementation of the programme
■ Improving carbon related data quality across the Trust by reviewing and updating
the metering arrangements and data collection and handling processes
■ Indentifying carbon reduction projects for implementation in next year’s
programme
■ Maintaining staff awareness through regular briefings and newsletters
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The Trust remains committed to:
■ Reducing our demand for energy and material resources
■ Extracting greater benefit from those resources
■ Sourcing our resources cleanly, renewably and sustainably
In the process we will be enhancing our work and therapeutic environments to contribute
to the health and well-being of users, partners and colleagues.
Summary of Performance
Area Non-financial data Financial data
(£)
2008/09 2009/10 2010/11 2008/09 2009/10 2010/11
Greenhouse Gas Emissions
Direct emissions (kgCOe) 5,618,641 4,985,571 4,424,325 1,032,392 975,398 805,379
Indirect emissions (kgCOe) 4,739,701 4,442,450 3,871,062 851,452 832,656 710,342
Waste minimisation and management, absolute values for total waste produced
Total waste arising
Not Not Not 376,132 365,421 321,000
available available available
Finite Resources
Water & waste water (m 3 ) 169,323 120,328 100,500 280,834 240,570 188,263
Electricity (kwh) 8,693,189 8,147,995 7,100,000 851,452 832,656 710,342
Gas (kwh) 29,922,945 26,558,113 23,000,000 974,444 925,849 755,304
Renewables (kwh) 905,769 803,680 760,000 46,520 41,312 37,916
Other (oil, propane in kwh) 189,948 162,786 195,000 11,428 8,237 12,159
A detailed breakdown of waste sent to landfill, waste recycled and waste incinerated is not
currently available.
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Community Involvement
At Surrey and Borders we take the involvement of our communities extremely seriously
both within local teams and at a Trust-wide level. This is achieved through a variety of
routes including our Foundation Trust membership, the Trust’s Forum of Carers and people
who Use Services (FoCUS), Trust representation on local networks and forums, outreach
work to hard-to-reach communities, and specific workshops and co-design events for
service developments.
The Trust’s Standards for Involving People, developed by people who use services and
carers, are actively used to enable teams to measure the levels of involvement of people
who use services and carers across seven core standards. These are:
1. Service users and carers are actively involved in person-centred care
2. There is effective and appropriate communication and information sharing
3. Service users and carers are consulted about new policies and proposals for change
4. Service user and carer involvement is promoted and supported at all levels in Trust
business
5. Service users and carers are involved in the monitoring and evaluation of services
6. There is supported involvement of service users and carers in the recruitment and
selection of staff
7. There is monitoring and evaluation of service user and carer involvement
During the reporting year the Trust has been developing its links with the 13 borough and
district councils in the areas that it serves to help promote well-being and to make people
aware of the range of services available through the Trust. We also ran five workshops
across Surrey to talk about developing our Community Mental Health Recovery Services
and to find out what people who use services and carers would want from the service.
Over 170 people attended these sessions, the feedback from which will inform the
development of recovery care pathways in the year ahead.
Compliments and Complaints
During 2010/11 the complaints team recorded a total
of 332 compliments and 132 complaints. In line with
regulatory requirements, we made contact with
every complainant to ensure all issues of concern
were identified and incorporated into an agreed
complaint plan prior to commencing our
investigation process. A full response detailing the
outcome of the investigation, and where appropriate
changes made to service provision, is provided to
every complainant by the Chief Executive.
28%
Compliments
72%
Complaints
Page 22 of 132

Of the 114 completed complaint investigations during the year, 50 were upheld. ‘Upheld’ is
the term used to record where one or more aspects of a complaint were warranted, and
an apology has been provided by the Trust.
It is also recognised that it is often possible to learn from complaints and improve service
provision when a complaint has not been upheld. Changes to processes and procedures
across all service areas have been made during the year as a direct result of concerns
raised via a complaint. Examples include appointment processes, discharge processes
between inpatient and community services and locum support to an individual clinic
including urgent referrals undertaken by another clinic.
During 2010/11, the Parliamentary Health Service Ombudsman confirmed receipt of seven
new requests for second stage review. Of those requests the initial review process is
ongoing with regard to four whilst the remaining three requests have been rejected by the
Ombudsman and the complainants advised.
Patient Information
Building on the Trust’s range of 72 medication patient information leaflets made available
in 2009/10, an online choice and medication resource was developed in the year and
subsequently launched in April 2011. The new website enables people who use services,
carers and professionals to find out more about side effects and alternatives to medication
as well as providing information on common mental health conditions. We have also been
working on a medicines diary to help people record their experiences of taking medicine. A
pilot project will commence in Summer 2011 with interested people who use services
before rolling out the diary Trust-wide.
Work has been underway with young people across services to help improve the
information available to individuals referred to services. This includes the creation of a
website with video clips of staff describing their role and promotional literature for the
Early Intervention in Psychosis Service and a DVD for people going to Child and Adolescent
Mental Health Services for the first time produced by Youth Advisors.
Walkers at the Surrey and Borders 2010 Get Moving anti-stigma event
Page 23 of 132

Staff Engagement
We are committed to providing an environment in which our staff can flourish in satisfying
jobs and rewarding careers. We aspire to keep our staff aware and involved in the
development of our services.
Surrey and Borders employs 2,814 people comprising:
■ 898 nursing staff and nurse students
■ 192 medical staff
■ 360 therapies staff
■ 705 healthcare assistants and other support
staff
■ 659 admin, clerical, estates and hotel
services staff
We made the following progress against our
workforce delivery plan during 2010/11:
7%
13%
23%
25%
32%
Nursing
Healthcare assistants
Admin & Clerical, Estates & Hotel
Therapies
Medical
■ Reduction in the use of temporary workforce
■ Reduction of the substantive workforce in line with the Annual Plan
■ Reduction of our level of sickness absence by 0.7 percent, to 4.39 percent
■ Developments in health and well-being initiatives for our workforce encouraging the
adoption of healthy life choices with improved results demonstrated in the 2010
NHS Staff Survey
■ Achievement of a 69 percent return rate on our participation in the NHS Staff
Survey which was the highest of all mental health trusts in the country
■ Consolidation of the supervision and appraisal process to improve the quality of
appraisals and supervision. 2010 NHS Staff Survey responses indicated that the
Trust maintained its above average performance
■ Utilisation of e-rostering to make the most efficient use of our staff and
commencement of the benefits realisation work by increased reporting from the
system
■ Increased utilisation of e-learning capabilities and opportunities for staff
Involvement and Communication
A wide range of events to involve staff in the work of the Trust have been established such
as regular professional conferences and quarterly leadership forums. During 2010 we have
sought to engage with our workforce through the monthly Chief Executive conversation
groups, Staff Question Time at a variety of sites and the programme of Director walkaround
visits to clinical teams. These initiatives allow us to hear personal accounts of the
issues that the teams are facing, understand the impact of Board decision making on our
teams and help monitor the environment throughout our services.
Page 24 of 132

A significant amount of planned change in 2010 has promoted close working of
management with our staff representatives and monthly meetings have enabled
discussion and consultation with staff union representatives on issues of concern to staff.
A new initiative of electronic comment on consultations has proved popular with staff.
A variety of communication methods are used to relay key information to staff including a
weekly electronic bulletin, an operational briefing and a monthly Trust newspaper. The
Trust’s staff intranet was relaunched in April 2010 to provide a fast and efficient means of
enabling corporate and clinical information to be shared with staff and also to promote
two-way communication. In July the communications team launched a monthly e-
newsletter to advise staff of service developments, the latest news on change programmes
and key quality initiatives.
In February 2011, we recognised the outstanding achievements of 27 individual staff
members and teams with our annual Staff Achievement and Recognition Scheme. An
award ceremony followed the submission of over 120 nominations from people who use
services, carers, partner organisations and staff.
NHS Staff Survey
The 2010 NHS Staff Survey was completed by 69 percent of Trust staff, which was the
highest in the country for mental health trusts. Overall, the outcome of the survey is
positive with the Trust improving its performance in the majority of areas identified for
improvement during 2010. This includes health and safety with 80 percent of staff
receiving training and improved reporting of errors, near misses or incidents.
Communication with senior management and staff had also improved above the national
average along with staff feeling supported by their immediate line manager.
While our staff did agree the Trust was a place they could recommend to work or receive
treatment, rating it on average 3.28 out of 5, this was marginally below the national
average for mental health trusts. The percentage of staff believing the Trust provides equal
opportunities for career progression has not improved on last year and we remain within
the lowest 20 percent of mental health trusts for this area. The number of staff working
extra hours and those feeling the pressure of work have increased. Possibly the
implementation of restructuring exercises across both operational and corporate services,
and the need to drive efficiencies at all levels, explains the deterioration in these particular
results during the past year. Action plans are being developed at a local team level to
address the areas of concern in each directorate and the Executive Board will be
monitoring progress against the plans during the year.
Page 25 of 132

Summary of Performance
2009/10 2010/11 Trust
Improvement /
Deterioration
Trust National
Average
Trust National
Average
Response rate 58% 55% 69% 55% 11% improvement
Top 4 ranking scores
Staff motivation at work 3.86 3.84 3.89 3.82 0.03 improvement
Percentage of staff
N/A N/A 15% 18% N/A
experiencing harassment,
bullying or abuse from
patients, relatives or the
public in last 12 months
Percentage of staff feeling 77% 76% 79% 75% 2% improvement
satisfied with the quality of
work and patient care they
are able to deliver
Percentage of staff feeling
pressure in last 3 months
to attend work when
feeling unwell
19% 19% 17% 19% 2% improvement
Percentage of staff
believing the Trust
provides equal
opportunities for career
progression or promotion
Staff recommendation of
the Trust as a place to
work or receive treatment
Percentage of staff
working extra hours
Percentage of staff
experiencing harassment,
bullying or abuse from
staff in last 12 months
Bottom 4 ranking scores
83% 90% 82% 89% 1% deterioration
3.34 3.43 3.28 3.49 0.06 deterioration
67% 63% 69% 65% 2% deterioration
N/A N/A 15% 14% N/A
Future Priorities and Targets
In 2011/12 our workforce priorities are:
■ Optimise the use of our staff through effective management, analysis and skill mix
review to ensure they are well equipped to deliver high quality services
■ Increase the use of apprenticeships within the organisation to assist in balancing our
workforce profile
■ Improve staff experience of working in the Trust and promote the use of flexible
working options
■ Reduce staff sickness absence by a further 0.5 percent
Page 26 of 132

■ Reducing the cost of our corporate workforce to bring the Trust in line with other
Foundation Trusts
In regard to staff engagement priorities for the year ahead we will focus on improving
areas where we scored ‘worse than average’ in the NHS Staff Survey.
The Trust’s key staff engagement priorities for the year ahead are to:
■ Develop job-related training for managers which will focus their attention on not
only absence management but also on other issues that impact upon people’s
health. The Management and Leadership Development Programme for first line
managers will also support this
■ Deliver a range of management, leadership and coaching programmes including a
master class on Leadership Development to all staff groups to help improve equality
and diversity awareness amongst staff
■ Raise awareness and develop communications of risk assessments
■ Encourage the online reporting of errors
■ Delivery of team-based learning programmes for Care Programme Approach, risk
assessment and suicide prevention
■ Develop Cognitive Behavioural Therapy capability through an internally delivered
learning programme
■ Introduce monitoring of promotion and career progression
■ Continue our support in developing the Trust’s vocational workforce
Progress against these priorities will be led by the Director of Human Resources and
monitored by the Executive Board.
ACORN Drug and Alcohol Service, Creativity and Innovation runner-up
Page 27 of 132

Equality and Diversity
During 2010 we marked the fourth year of our Equality and Human Rights Strategy,
Diversity Yes Stigma No, which identifies the following priorities:
■ Accessible, equitable service provision
■ Competent and confident staff
■ Meaningful engagement with communities
■ Representative leadership group
■ Stigma identification and elimination actions
The Equality and Human Rights Steering Board provides clear leadership and challenge
across the equality and human rights agenda including monitoring progress across the
Trust. This work is supported by the Diversity and Inclusion Team which is led by the
Director of Corporate Affairs. The Steering Board sets performance indicators for targeted
improvements to be made each year.
The year 2010/11 saw us develop our Single Equality Scheme and action plan to
incorporate the changes within the Equality Act 2010 to ensure compliance with new
equality legislations. With the involvement of staff representative groups, people who use
services and their carers and other relevant third sector and statutory groups, we have
now established a robust action plan that will inform the equality outcomes objectives
which are due to be published in April 2012.
Our Access to Services report was published this year with extended information for all
protected characteristics to support our equality and human rights priorities in designing
and delivering services that can respond to the differing needs of our local communities.
This forms an important starting point from which to develop future reports and to review
our progress in future years. Our work over the year means that we are well placed to
implement the NHS Equality Delivery System which will support NHS organisations in the
assessment and compliance with the Equality Act.
The Trust’s commitment to embedding equality, diversity and human rights into our core
business has been recognised and commended by the NHS Employers Partners. As a result,
we have been invited to utilise our expertise in more challenging and critical commissioner
and provider work streams, aligned to the work of the Equality and Diversity Council.
The Trust is a Stonewall Champion and this year’s Stonewall Workforce Equality Index
results have shown a marked improvement in our positioning. Our Lesbian, Gay, Bisexual
and Trans staff network is now established and progressing to support staff and raise
awareness. The Trust’s Black & Minority Ethnic (BME) Staff Network has actively
campaigned to improve the South East Coast BME Network Race Equality Service Review
action plan. Work is underway to establish a pilot programme to enable this work to
progress with meaningful outcomes for our BME staff. The Trust’s Disability Staff Network
and the Christian Fellowship Forum are now established and progressing well.
Page 28 of 132

Future Priorities and Targets
The Trust’s key Equality and Diversity priorities for the year ahead will focus on the
following areas:
■ Ensure changes in Equality Act 2010 legislation requirements and public sector
equality duties are met and set equality outcomes objectives by April 2012
■ Publish sufficient information to demonstrate that we have complied with the
public sector general equality duty by December 2011
■ Review the Single Equality Scheme by March 2012
■ Progress equality analysis reflecting the changes within Equality Act 2010 and
address effects on equality for all protected characteristics
■ Set targets to address diversity and equality areas with low scores achieved in the
NHS Staff Survey
■ Progress diversity, equality and human rights training
■ Continue development of the Access to Services reporting, utilising the benefits of
the single electronic patient record system, RiO
Progress against these priorities will continue to be monitored by the Trust’s Equality and
Human Rights Steering Board and Executive Board through its key performance indicators.
Summary of Performance for Foundation Trust Membership
Membership
2008/09
Membership
2009/10
Membership
2010/11
Age Band Number % Number % Number %
0 - 16 7 0.14 4 0.08 7 0.14
17 - 21 79 1.56 66 1.25 61 1.24
22+ 4252 84.09 4262 80.77 3836 77.90
Undisclosed 718 14.21 945 17.9 1020 20.71
Grand Total 5056 5277 4924
Ethnic Origin Number % Number %
White 3989 78.89 4083 77.36 4429 89.95
Mixed 41 0.81 41 0.76 58 1.18
Asian or Asian British 123 2.43 141 2.67 146 2.97
Black or Black British 52 1.03 52 0.99 52 1.06
Other 133 2.63 40 0.79 45 0.91
Undisclosed 718 14.21 920 17.43 194 3.94
Grand Total 5056 5277 4924
Gender Number % Number %
Female 1660 32.83 2832 53.66 3060 62.14
Male 2678 52.96 1701 32.24 1845 37.47
Undisclosed 718 14.21 744 14.10 19 0.39
Grand Total 5056 5277 4924
Page 29 of 132

Summary of Performance for Trust Staff
Staff
2008/09
Staff
2009/10
Staff
2010/11
Age Band Number % Number % Number %
16 - 20 17 0.50 6 0.19 0 0
21 - 25 74 2.18 75 2.37 57 2.07
26 - 30 192 5.65 177 5.58 163 5.93
31 - 35 304 8.94 288 9.09 243 8.84
36 - 40 391 11.50 375 11.83 359 13.07
41 - 45 496 14.59 431 13.60 392 14.27
46 - 50 532 15.65 540 17.03 489 17.8
51 - 55 525 15.45 479 15.11 463 16.86
56 - 60 479 14.09 444 14.01 378 13.76
61 - 65 287 8.44 252 7.95 197 7.17
66 - 70 82 2.41 88 2.78 3 0.10
71 & above 20 0.59 15 0.47 2 0.07
Grand Total 3399 3170 2746
Ethnic Origin Number % Number % Number %
White British 1915 56.34 1810 57.10 1564 56.96
White Irish 91 2.68 84 2.65 77 2.80
White Any Other White Background 247 7.27 254 8.01 224 8.16
Mixed White & Black Caribbean 13 0.38 14 0.44 11 0.40
Mixed White & Black African 7 0.21 7 0.22 6 0.22
Mixed White & Asian 17 0.50 17 0.54 13 0.47
Mixed Any Other Mixed Background 32 0.94 29 0.91 19 0.69
Asian or Asian British Indian 112 3.30 110 3.47 90 3.28
Asian or Asian British Pakistani 15 0.44 14 0.44 14 0.51
Asian or Asian British Bangladeshi 2 0.06 1 0.03 2 0.07
Asian or Asian British Any Other Asian 286 8.41 244 7.70 211 7.68
Black or Black British Caribbean 94 2.77 84 2.65 63 2.29
Black or Black British African 248 7.30 227 7.16 209 7.61
Black or Black British Any Other Black 21 0.62 26 0.82 19 0.69
Chinese 33 0.97 29 0.91 24 0.87
Any Other Ethnic Group 205 6.03 184 5.80 167 6.08
Not Stated 61 1.79 36 1.14 33 1.20
Grand Total 3399 3170 2746
Gender Number % Number % Number %
Female 2399 70.58 2286 72.11 1986 72.32
Male 1000 29.42 884 27.89 760 27.68
Grand Total 3399 3170 2746
Disabled Number % Number % Number %
No 2109 62.05 2049 64.64 1779 64.79
Yes 123 3.62 112 3.53 97 3.53
Not Declared 349 10.27 304 9.59 228 8.3
Unknown 818 24.07 705 22.24 642 23.38
Grand Total 3399 3170 2746
Page 30 of 132

Regulatory Ratings
Monitor requires each Foundation Trust Board to submit a quarterly report. Performance
is monitored against these reports to identify where potential or actual problems might
arise. Monitor also uses these reports to assign each Trust with a financial and governance
risk rating. These ratings are designed to indicate the risk of a failure to comply with the
terms of the authorisation.
Performance Against Plan
The Trust was rated ‘Green’ for its governance risk throughout the year which is in line
with its planned position. The financial risk rating is set on a scale of 1 – 5, where 1
represents the highest risk and 5 the lowest. The Trust has maintained a consistent rating
of 3 throughout the year.
Financial
risk rating
Governance
risk rating
Financial
risk rating
Governance
risk rating
Annual Plan
2009/10
Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10
3 3 3 3 3
Green Green Green Green Amber
Annual Plan Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
2010/11
3 3 3 3 3
Green Green Green Green Green
Financial Accounts
The financial information presented in this Annual Report covers the year from 1 April
2010 to 31 March 2011. The accounts have been prepared under a direction issued by
Monitor.
After making enquiries, the Directors have a reasonable expectation that the NHS
Foundation Trust has adequate resources to continue in operational existence for the
foreseeable future. For this reason, they continue to adopt the going concern basis in
preparing the accounts.
The Trust has complied with the cost allocation and charging requirements set out in HM
Treasury and Office of Public Sector Information guidance.
Audit Information
As far as the Directors are aware, there is no relevant audit information of which the
Trust’s auditors are unaware. They have taken all of the steps that they ought to have
taken as Directors in order to make themselves aware of any relevant audit information
and to establish that the Trust’s auditors are aware of that information.
Page 31 of 132

External Audit
The Trust’s external auditor is the Audit Commission. For the year 2010/11 expenditure on
external audit fees was £76,130 (including VAT) for statutory audit work. Under its Advice
and Assistance powers, the Audit Commission also reviewed the Trust’s governance
arrangements of its Charitable Funds at a cost of £8,500 (including VAT). This additional
work, requested by the Trust, is over and above the statutory audit work and is managed
through the terms of engagement to ensure that the independence of external audit is not
compromised.
Lisa Dakar, Leadership Award runner-up
Page 32 of 132

Operating and Financial Review
Operating Review
Throughout the year our teams have worked hard to deliver the changes outlined in our
service plan, which improve the experiences of people who use services, their carers and
staff. Notable amongst these have been:
■ Full registration of all social care services with the Care Quality Commission and
successful lifting of the two conditions placed against the Trust’s health care
services
■ Formal Section 75 agreement with Surrey County Council signed to enhance
integrated working in adult community mental health teams with health care staff
enabled to undertake carers assessments
■ Development of 11 Community Mental Health Recovery Services to replace existing
adult Community Mental Health Teams for launch in April 2011
■ Successful introduction HoNOS (Health of the National Outcomes Scales) to record
outcome measures adults and older adults using mental health services
■ Commenced development of integrated older adult mental health teams through
provision of social care practitioners within each team
■ Progression of the Social Care Change Programme to create more independent
living options for people with learning disabilities with the majority of homes now
transferred to new arrangements
■ Improved performance in the national NHS Staff Survey particularly around staff
feeling supported by their line manager and receiving health and safety training
■ Significant improvement in the national inpatient survey with 55 percent of
individuals rating their overall care as excellent or very good compared with 42
percent in 2009
■ Full implementation of our single electronic patient record system, RiO, with the
final installation concluded in September 2010
■ Planning permission approval for the development of a new mental health hospital
in Guildford as part of the Trust’s plans to create respectful and therapeutic
environments for its most vulnerable individuals
■ Continued progress in rationalising the Trust’s estate of out-dated buildings
Financial Performance
The Trust reported a deficit of £313k during the year which was caused by the inclusion of
impairment (reduction) in the value of fixed assets of £1,867k. The current economic
climate has led to further reductions in the value of land and buildings held by the Trust
which, without sufficient revaluation reserves, has adversely impacted upon the income
and expenditure account.
Page 33 of 132

If this impairment was excluded, the Trust would have reported an operating surplus of
£1,554k, which was only £126k lower than the original financial plan. This position included
two other significant non-recurrent items in addition to the impairment – £3,325k profit
generated from the disposal of fixed assets and £1,764k of redundancy payments which
have arisen from the Social Care Change Programme to transfer social care housing from
the NHS to independent providers.
The Trust successfully delivered £9,100k of cost improvement plans during the year against
an originally planned level of £10,800k. This shortfall was due to some over-optimism
about the level of savings that could be delivered while the development phase of other
plans took longer than anticipated leading to delays in their implementation and the
realisation of savings resulting in pay costs ending the year £4,000k higher than originally
planned – this was offset by other savings delivered.
Other significant financial problems have been caused by the delay in the implementation
of the Social Care Change Programme and the shortfall in income from commissioners.
Plans to identify suitable alternative packages of care for all of the people who use these
services have taken significantly longer than was originally hoped or envisioned. This has
meant that many of the homes now have a reduced level of occupancy as residents have
been relocated individually and unfortunately the local social services have not funded
these resulting voids, despite assurances previously given.
The income and expenditure surplus margin for the year was zero percent as the Monitor
risk ratings exclude certain items including impairments, profit/loss on disposal and
restructuring costs. Overall, the Trust achieved its targeted financial risk rating of 3, as
shown below:
2010/11
Plan Actual
EBITDA Margin 7.7% 6.7%
EBITDA % Achieved 100% 90%
Return on Assets 4.7% 3.3%
I&E Surplus Margin 1.0% 0.0%
Liquid Ratio 33.3 31.3
Weighted Average 3.4 3.2
Overall Rating 3 3
To achieve its financial targets, the Trust had set very challenging cost improvement plans
totalling £10.8m spread between both operational and corporate departments. While the
Trust did not achieve £4.8m of these original plans, alternative plans identified during the
year and tight control of all budgets meant that this shortfall was offset during the year.
The Trust spent £7,873k on capital projects during the year including improving the built
environment and IT across the Trust and investing in strategic schemes. This money was
funded from the disposal of existing surplus assets and the generation of financial
surpluses.
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The level of investment was £2,652k lower than originally planned due to delays in the
planned disposal of surplus assets and so the strategic capital programmes were reviewed
based on the available resources.
Better Payment Practice Code
The Better Payment Practice Code requires the Trust to aim to pay all undisputed invoices
by the due date or within 30 days of receipt of goods or a valid invoice, whichever is the
later. Payment details are as follows:
Number £000
Total non-NHS trade invoices paid in the period 30,861 37,902
Total non-NHS trade invoices paid within target 29,319 35,430
Percentage of non-NHS trade invoices paid within target 95% 93%
Total NHS invoices paid in the period 878 10,686
Total NHS invoices paid within target 765 8,854
Percentage of NHS invoices paid within target 87% 83%
Management Costs
Management costs equal £11,817k. Income for the year was £170,128k, therefore
management costs represent 6.95 percent of income.
Ill-health Early Retirements
During the year there was one early retirement from the Trust agreed on the grounds of illhealth.
The estimated additional pension liabilities of this ill-health retirement will be
£119,425. This retirement represented 0.36 per 1,000 active scheme members. The cost of
this ill-health retirement will be borne by the NHS Business Services Authority Pensions
Division.
Annie Ryan, Creativity and Innovation runner-up
Page 35 of 132

Future Plans
Operating Plans
Our focus for the coming year will be to continue to improve the quality of our services
and the experience of individuals through working with our partners, whilst ensuring our
services present efficiency and value for money.
Our commitment moving forward is to develop system-wide care pathways to provide
improved outcomes for individuals and to ensure our staff are well-developed and enabled
to deliver high quality services in a very challenged health and social care system.
In particular, 2011/12 will see the implementation of the following service change plans:
Community Teams
■ Relocation of Community Mental Health Services in Waverley to one single location
■ Development and implementation of our Community Mental Health Recovery
Services through clustered care and borough based services
■ Implementation of changes in light of Surrey’s older people’s mental health strategy
outcomes
■ Development of integrated mental health service model in Hampshire
Specialist Community Services
■ Relocation of Children and Adolescent Mental Health Services and Early
Intervention Services to secure more fit-for-purpose environments including
creation of a single Elmbridge base and Woking/Runnymede base
■ Development of ‘Think Family’ approach by co-ordinating support to secure better
outcomes and predictive risk model
■ Development of young person’s Eating Disorder Service
■ Development of single county-wide Mental Health Forensic Service
24 Hour Acute Assessment and Treatment
■ Development of intensive crisis support and hospital treatment for children and
adolescents with mental ill-health
■ Enabling works for the development of our new hospital in Guildford
Psychological Medicine
■ Further development of our liaison and health psychology services with district
general hospitals
■ Development of acute liaison for people with learning disabilities in prisons
■ Redesign of older people’s services to extend memory services to support admission
avoidance
Page 36 of 132

Individualised Support Programmes
■ Closure of our day services as part of the Social Care Change Programme
implementation
■ Rationalisation of other day programmes
■ Roll-out programme for Self Directed Support
■ Accelerated improved performance on the numbers of carers receiving carers
assessments
■ Development of Loddon Alliance specialist supported living programme
Registered Residential Care Homes
■ Completion of our Social Care Change Programme
24 Hour Active Treatment and Support
■ Development of complex needs services for people with learning disabilities
including rationalisation of bed capacity
■ Reprovision of residential health care for people with learning disabilities in
Caterham
■ Review and rationalisation of our acute therapy programmes
■ Redesign of our residential recovery and rehabilitation centres
■ Completion of our NHS Campus reprovision programme
■ Extension of our drug and alcohol bed capacity
Financial Plans
As a Foundation Trust we can consider our plan over a three year period. In 2011/12 we
are aiming to achieve the following key financial targets:
■ Financial risk rating of 3
■ Planned deficit of £1.5m
To achieve this deficit target the Trust will deliver a cost improvement programme totalling
£7.6m. The planned deficit does not present a risk to the ongoing stability and
sustainability of the Trust as it includes £2.6m of non-recurrent costs and so the Trust will
deliver surpluses in future financial years.
The key issues shaping the Trust’s Financial Plan and which must be managed carefully in
2011/12 are:
■ The impact of the continued income loss from the Trust’s Social Care Change
Programme and NHS Campus services, where services continue to run at a deficit
due to the transition and voids. We need to ensure this is non-recurrent and that
the planned closure is delivered in 2011/12
■ The delivery of the required recurrent cost improvement programme in operational
and corporate services
Page 37 of 132

■ The stringent management of the Trust’s capital plan:
­ To prioritise essential expenditure over developmental priorities; this requires
the deferral of the Trust’s key development - the redevelopment of Farnham
Road Hospital site - from a start date of June 2011 to June 2012
­ To ensure success of the Trust’s planned disposal programme, notably the
disposal of the Oaklands site in Caterham, to achieve the receipt in 2011/12.
This is dependent upon the consolidation of corporate services into
Leatherhead and the development of new health care housing on the retained
Oaklands site
■ The management of risks to the financial plan through downside planning and
mitigations and the prudent pursuit of upside business development opportunities
Risks and Uncertainties
The Trust’s key risks arise if we fail to:
■ Focus on quality and safety and describe, monitor and report clearly our
performance against our agreed key quality and safety indicators as set out in our
Quality Account
■ Grow and diversify our business to respond to market changes in order to make us
more sustainable and take opportunities to develop new business
■ Engage and manage our staff effectively and continue to improve staff management
and experience
■ Work in partnership with health and social care partners, including commissioners,
to make the best use of collective resources available to us
■ Manage our finances effectively in the economic climate and fail to deliver increases
in productivity and efficiency required
These risks are monitored by the Board through our governance structures and plans
are in place to address them.
Porters Team at Farnham Road Hospital, Team of the Year
Page 38 of 132

Quality Report
Statement on Quality from the Chief Executive
Our focus over the last year has continued to be on providing high quality services focused
on excellence in all that we do by ensuring our staff are well supervised, developed and
supported to deliver excellent health and social care in a very challenged environment.
We know the successes we have achieved over the last year have been as a result of the
hard work of our staff to improve our services for the people who use them and their
carers. We have learned that such success can only be achieved through the rigour of our
constant attention, from ward to Board, on the experience, outcomes and safety of what
we do and a willingness to learn from both success and when things go wrong. As part of
our commitment to doing this the Board signed the Being Open declaration in March 2011.
Sadly the experience six years ago of one person was highlighted in the Health Service
Ombudsman’s report “Care and Compassion” published this year which brought to all our
attention the devastating consequences for people and families when things do go wrong.
We are committed to ensuring our focus on quality makes sure experiences like these are
not repeated in our services today.
Our ability to systematically monitor the quality of each service is at the heart of ensuring
this. During the last year our Board walk-arounds and annual programme of periodic
service reviews (which are aligned to the Care Quality Commission’s essential standards for
quality and safety) have ensured a continual measurement and dialogue about quality and
safety on the ground. We have also improved the frequency with which we can hear direct
feedback from people using our services to further improve care provision through the
introduction of our patient experience trackers.
We are proud of the achievements we have made during the last 12 months to improve
our practice in the two areas where we received conditions to our registration with the
Care Quality Commission. These conditions were both lifted in 2010 after improved
communication with staff combined with a tough approach to confronting poor practice
helped to turn around performance. The Trust has now been commended as being one of
the best in the country for demonstrating efficient practices for recording capacity to give
consent to treatment. In the Autumn we achieved full registration of all our health and
social care services with the Care Quality Commission.
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Other enabling programmes which have underpinned our quality improvements in the
year include:
■ Continued improvements to our built environment which has helped us to achieve:
­ Compliance with Delivering Same Sex Accommodation (DSSA) self
assessment by the target date of 31 March 2011 through the implementation
of our action plan in 2010/11
­ Planning permission for our new hospital build at Farnham Road Hospital in
Guildford to create a new modern, efficient and therapeutic environment for
services
■ Our full implementation of RiO, the electronic records system, across the majority
our services last year enabling patient records to be shared between teams more
quickly and reliably. We were the first trust in the South East to achieve this and our
project team has been commended for their success
I am proud of the real progress we are making on improving our services and the
experiences of the people who use them and our staff which has been evidenced in the
improved performance we have received in both the national patient and staff surveys
during the year. Our focus in the coming year will continue to build on our successes to
date and target those areas where we want to see further improvement to meet our
ambition to be one of the top performing trusts in the country in all areas.
To the best of my knowledge the information in this document is accurate.
Fiona Edwards
Chief Executive
6 June 2011
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Quality Improvement Priorities for 2010/11
The information below outlines the Trust’s quality improvement priorities for 2010/11 and
the progress made against these:
During 2009/10 the Trust participated in the Foundation Trust regulator’s (“Monitor”)
Board Leadership for Quality programme to support its strategic focus on quality
improvements. As a result of this work the Board has set ambitious targets for the next
three to five years and has defined its critical components for quality as safety, outcomes
and experience of people who use services and staff and value for money.
The Trust set the following clinical quality improvement priorities for 2010/11:
Experience
1. Improve the Trust’s performance within the NHS Community Mental Health Survey to
the next quartile for overall satisfaction
Progress - The Trust can demonstrate significant improvement in the 2010 NHS
Community Mental Health Survey. The final response rate for the Trust was 38 percent
which is an increase by 10 percent on last year’s response rate. The Trust was in the upper
ratings of the 56 participating NHS providers.
The care that people using services received from our mental health services in the last 12
months definitely improved with 25 percent of respondents saying our care was good,
which is an increase of 7 percent from the previous year. However, when comparing the
rating of excellent and very good there was an overall decrease of 6 percent from last
year’s result.
When compared to survey results from the previous year the 2010 survey identified areas
of improvement and also areas where our performance has decreased over the year. We
have used these findings to put systems in place to improve our service provision in the
community. Below is a summary of the key areas where the Trust performed above or in
line with the national result with an example of some of the questions answered under
each survey heading.
Key Areas Where Performance is Above the National Result
■ Your Care and Treatment - People using services had been seen by someone from
the mental health services in the past month, 65 percent (national average 60
percent)
■ Talking Therapies - Mental health or social work staff had discussed talking therapy
with the person using services in the past 12 months, 60 percent (national average
53 percent)
■ Crisis Care - People using services were given a number of someone from the local
mental health service that they could phone out of hours, 63 percent (national
average 51 percent)
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■ Day to Day Living - People using services said they were definitely supported to find
or keep work eg being referred to an employment scheme, 32 percent (national
average 28 percent)
Key Areas Where Performance is Below or Equal to the National Result
■ Health and Social Workers - People using services felt this person treated them
with respect and dignity, 87 percent (same as national average)
■ Medications - People using services were prescribed medication for mental health
conditions, 91 percent (4 percent increase on 2009, national average 89 percent)
■ Your Care Coordinator - Person using services felt they could contact their care
coordinator or lead professional always, 63 percent (4 percent decrease on 2009,
national average 72%)
■ Your Care Plan - People using services had received a copy of their care plan, 42
percent (same as national average)
■ Your Care Review - People using services said they were definitely given the chance
to express their views at the care review meeting, 69 percent (6 percent decrease
on 2009, national average 70 percent)
Data source: Community Mental Health Survey. This is national data that is governed by
standard national definitions and the indicator has been chosen for the Quality Accounts
because it provides information that allows for effective national benchmarking.
2. Improve the Trust’s performance within the NHS National Staff Survey to the next
quartile for overall satisfaction
Progress - 2010 has been a challenging year for the NHS as a whole and at Surrey and
Borders we have been working through significant change processes which may impact on
staff satisfaction. The Trust introduced a new initiative of Staff Question Time in 2010 to
promote discussion between the Executive Board and staff on topical issues, with support
from staff Governors, and we continued our programme of Trust Board visits to sites
across the Trust.
We also improved our participation in the 2010 NHS Staff Survey to 69.59 percent of all
staff compared with 60.31 percent in 2009. The Trust has received the feedback from the
Staff Survey and we are pleased that there are improvements in many areas. The highlights
from the survey are as follows:
Top Ranking Results
The four key findings for which our Trust compares most favourably with other mental
health/learning disability trusts in England were as follows:
■ Staff motivation at work
■ Staff experiencing harassment, bullying or abuse from patients, relatives or the
public in the last 12 months (positive result)
■ Staff feeling satisfied with the quality of work/patient care they are able to deliver
■ Staff feeling under pressure to attend work when feeling unwell (positive result)
Page 42 of 132

Where Staff Experience has Improved
The four areas where we have made significant improvements during 2010 were:
■ Staff having equality and diversity training
■ Staff receiving health and safety training
■ Staff job satisfaction
■ Support from immediate line managers
Lowest Ranking Results
The four areas where we performed least well were:
■ Staff believing the Trust provides equal opportunities for career progression or
promotion
■ Staff recommendation of the Trust as a place to work or receive treatment
■ Staff working extra hours
■ Staff experiencing harassment, bullying or abuse from staff in the last year
Where Staff Experience has Deteriorated
The two areas where staff experiences have deteriorated since the 2009 survey were:
■ Work pressure felt by staff
■ Staff recommendation of the Trust as a place to work or receive treatment
The Trust is in the process of formulating an action plan to implement changes in the areas
that need addressing and to maintain good performance in other areas.
Data source: Human Resources Workforce Report. This is reported to Executive Board
through the Trust Service Quality Performance Report. This is national survey data
governed by standard national definitions and the indicator has been chosen for the
quality accounts because it provides information that allows for effective national
benchmarking.
3. All services to achieve an 85 percent threshold in the Vision and Values section of the
Trust’s internal auditing tool, the periodic service review
This data was not collected in the same format in 2009 making it difficult to compare this
with data from 2010. The data below will however be used to benchmark our performance
in the future.
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Progress
95%
94%
93%
92%
Average Score
Children and Young People
24/7 Services
Active Support and Reg Social Care
Older Adult and Learning Disability Community Teams
Adult Community Teams
Specialist
Services
2010 Vision and Values Sub-Section Scores
Average Involve Not Create
Score Ignore Respectful
Places
Open,
Inclusive &
Accountable
Treat People
Well
Children and Young People’s services 93% 92% 94% 91% 93%
24/7 services 93% 92% 94% 93% 93%
Active Support & Treatment /
93% 91% 94% 94% 93%
Registered Social Care
Community Teams for People with 94% 92% 95% 95% 95%
Learning Disabilities and Older
Person’s Mental Health
Community Teams for Working Age 93% 94% 92% 93% 93%
Adults
Specialist Services & Psychological
Medicine
95% 95% 93% 97% 94%
The Trust Board is very pleased with the high performance in these areas. Our Vision and
Values are central to high quality delivery of services and these high scores indicate that
our clinical teams are continuing to improve.
Areas where the teams score below the required levels are immediately addressed and
then reassessed within three months. The periodic service review scores are regularly
reported to the Executive Directors and Trust Board.
Data source: Internal Periodic Service Review. This is locally collected data and not
governed by standard national definitions as it is based on local priorities. The indicator
has been chosen for the Quality Accounts because it provides information based on the
Trust’s internal audit tool, which is acknowledged by the Care Quality Commission, to
allow for effective internal cross-service benchmarking.
Page 44 of 132

Effectiveness
1. Introduce Health of the Nation Outcome Scales (HoNOS) reporting as a clinical
outcome measure to monitor recovery progress for people who use services
Progress - The facility to routinely collect HoNOS scores became available at the end of
2010 with the roll-out of the Trust’s single electronic patient record system, RiO. Due to
data not being available prior to this, we are unable to benchmark our current
performance against a previous year. The number of people who use our working age
adult, older people’s and specialist services (excluding Drug and Alcohol and Learning
Disability Services) with a completed recent HoNOS score as of 13 April 2011 is as follows:
Total No of
Service Users
No of Service
Users with
HoNOS
No of Service
Users without
HoNOS
Adult Mental Health Services 7861 6297 1564
Older People’s Mental Health Services 6230 4847 1383
Specialist Services 1198 998 211
TOTAL 15289 12142 3158
Data source: RiO electronic patient records data, reported to Executive Board through the
Trust Service Quality Performance Report. This is locally collected data and governed by
standard national definition and has been selected as an effective tool to measure
progress against this indicator.
2. Reduce staff sickness absence to 4 percent
Progress - The Trust’s sickness absence rate has steadily reduced throughout 2010/11 from
5.04 percent in January 2010 to 4.29 percent in March 2011 which is an improvement from
the 5.09 percent reported in 2009/10. This is however slightly above the Trust’s target of 4
percent. Short-term sickness absence makes up 80 percent of our sickness absence and
managers are beginning to use absence reporting from electronic staff records to address
attendance issues within the workforce. Improvement in this area is a key priority for
Surrey and Borders in 2011/12.
Data source: Human Resources Workforce Report. Reported to Executive Board through
the Trust Service Quality Performance Report. This is locally collected data not governed by
standard national definitions and it has been chosen for the Quality Accounts because it is
a core priority outlined in the 2009/10 Quality Accounts.
3. Achieve 90 percent validation for all patient records in the single electronic patient
record system, RiO
Progress - The Trust reports this data in its Service Quality Performance Report on a
monthly basis and is monitored at the Trust Executive Board and Trust Board. This data is
also monitored by the Operational Management Board and clinicians have been supported
to understand the importance of validation.
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RiO has now been in use for over a year by the first teams to use it and some real clinical
and operational benefits have been delivered. The Trust is considering additional benefits,
now that the use of the system is stable across all teams. These additional benefits will
help us to identify areas of best practice and improve our provision of services.
The Trust has exceeded the 90 percent level of performance with 97.5 percent of clinical
notes validated as at 31 March 2010/11.
Data source: RiO, reported to Executive Board through the Trust Service Quality
Performance Report. This is locally collected data not governed by standard national
definitions and it has been chosen for the Quality Accounts because it is a core priority
outlined in the 2009/10 Quality Accounts.
Safety
1. Maintain the Trust’s top level performance on staff appraisal and supervision within
the NHS National Staff Survey
Progress - The Trust is currently recording its appraisal data as 82 percent of staff having
received an appraisal within the last 12 months. This is a fall from the 83 percent of staff
saying that they received an appraisal in the same period in 2009/10. The Human
Resources Directorate is linking with senior managers across the Trust to ensure that data
is recorded accurately and that this target is achieved and maintained.
Outcomes of the Care Quality Commission comparative data show that we are currently
one percent above the national average for mental health trusts with 83 percent of staff
who completed the Staff Survey saying that they were appraised in 2010.
Data source: Human Resources Workforce Report, reported to Executive Board through
the Trust Service Quality Performance Report. This is locally collected data governed by
standard national definitions and it has been chosen for the Quality Accounts because it is
a core priority outlined in the 2009/10 Quality Accounts.
2. Ensure Trust reporting of incidents to the National Patient Safety Authority (NPSA)
aligns with the national benchmark for mental health trusts
Progress - The Trust’s latest NPSA Organisational Feedback report was published during
September 2010. This report is the most recent published by the NSPA and covers patient
safety incidents that occurred between 1 October 2009 and 31 March 2010. During this
period the Trust reported 825 incidents, which equated to a reporting rate of 12.8
incidents per 1,000 bed days. This is a decrease in the number of incidents reported for 1
April until 30 September 2009, which stood at 870. Both performances were in keeping
with the middle 50 percent of reporters in the same peer group.
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The Trust reported patient safety incidents in six out of six months to the National
Reporting and Learning System (NRLS) with 50 percent of incidents being submitted more
than 59 days after the incident occurred. This compares with 44 days after the incident
occurred for 50 percent of all other trusts in the same peer group with our performance
again falling within the middle 50 percent of reporters.
The Trust reported 11 incidents relating to medication which equates to a reporting rate of
0.17 per 1,000 bed days. This is in the lowest 25 percent of reports in the same peer group.
Data source: National Patient Safety Agency (NPSA) Incident Report, reported to the
Executive Board through the Quality Report. This information is governed by standard
national definitions as it is derived from national data. This indicator was chosen as it
provides suitable benchmarking opportunities with other similar organisations and was a
key priority outlined in the 2009/10 Quality Accounts.
3. Ensure 95 percent of patients admitted under the Mental Health Act are assessed for
their capacity to give consent to treatment on admission and that the assessments
are recorded within the patients’ records
Progress - The Trust has been closely monitoring to ensure that patients admitted under
the Mental Health Act are assessed for their capacity to give consent to treatment on
admission and that the assessments are recorded within the patients’ records. Regular
audits have shown excellent compliance at 98 percent of all detentions. Where there have
been breaches this has been swiftly rectified. The Trust is now planning to undertake an
audit to measure the quality of this process.
The Trust is unable to provide comparative data for this from previous years as it was not
collected in this way. The Trust will continue to monitor this closely and The Trust will be
able to show comparative data next year.
In addition to these priorities, the Board has monitored the quality of the Trust’s services
against a number of key performance indicators, including the frequency and trends of
serious untoward incidents and the timely investigation, identification and implementation
of lessons to be learnt as a result.
Data source: Internal data, reported to Executive Board through the Trust Service Quality
Performance Report. This information is governed by standard national definitions and it
has been chosen for the Quality Accounts because it is a core priority outlined in the
2009/10 Quality Accounts.
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Quality Improvement Priorities for 2011/12
Clinical Quality Priorities Targets / Measures for 2011/12
Experience
To improve ‘year on year’ the
experiences for people who use our
services, their carers and families and
staff
To be a top performing Trust in both
national patient and staff surveys by
2013/14 in all indicators
Effectiveness
To provide evidence to commissioners
and individuals of the effectiveness of
our services and the outcomes they help
people achieve
Safety
To demonstrate the safety of our
services and the care, treatment and
support they provide
1. Improve the Trust’s performance within the national
service user survey to reach the next quartile in the three
areas where the Trust’s performance fell below desired
levels in 2010
2. Improve the Trust’s performance within the national staff
survey to reach the next quartile for overall satisfaction and
maintain a return rate of over 69 percent of staff
3. Improving the experience of carers by ensuring more
receive timely assessments of their needs. Carers’
assessments will be offered to at least the nominated
carers of 26 percent of adults on our caseload (Surrey
County Council target)
1. Use Health of the Nation Outcome Scales (HoNOS)
reporting as a clinical outcome measure to monitor
recovery progress for people who use services
2. Reduce staff sickness absence to 4 percent
3. Use Child and Adolescent Mental Health Outcomes
Research Consortia (CORC) results to demonstrate
improvements for people using this service
1. Ensure 95 percent of clinical staff are up to date with their
clinical risk assessment training
2. Ensure 95 percent of the action plans from investigations of
serious untoward incidents are completed within the set
timescale
3. Ensure 97 percent of patients admitted under the Mental
Health Act are assessed for their capacity to give consent to
treatment on admission and that the assessments are
recorded within the patients’ records
These targets have been developed by the Board building on our learning through the year
in talking with people who use services, carers, governors, commissioners, our clinical
leaders, staff and other stakeholders and regulators. They have also been identified
through our existing performance monitoring results, including national surveys. Our
progress against these targets will be reported to the Trust Board throughout the year by
the Director of Quality & Performance (Nurse Director). These targets are core to the
Trust’s Annual Plan and as such will form part of our quarterly performance reporting to
the regulator (“Monitor”) on our delivery.
We will support the achievement of this by continuing our focus on the importance of
managing people well through appraisal and supervision, and identifying and developing
staff, particularly our local leaders, to reach their full potential within the organisation.
These targets will form our balance scorecard for 2010/11. Our progress on delivering
these will be reported publicly throughout the year. At the end of the year we will publish
this progress in our Quality Account 2011/12.
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Statements of Assurance from the Board
Review of Services
During 2010/11 Surrey and Borders Partnership NHS Foundation Trust provided 194
services. The number of services and how these are configured changes over time.
Consequently the periodic service review annual report indicates that 172 services had a
review.
Surrey and Borders Partnership NHS Foundation Trust has reviewed all the data available
to it on the quality of care in 100 percent of these services through the periodic service
review process.
The income generated by the services reviewed in 2010/11 represents 100 percent of the
total income generated from the provision of services by Surrey and Borders Partnership
NHS Foundation Trust for 2010/11.
Participation in Clinical Audits
During 2010/11 nine national clinical audits and no national confidential enquiries covered
NHS services that Surrey and Borders provides.
During 2010/11 Surrey and Borders Partnership NHS Foundation Trust participated in 100
percent of clinical audits and national confidential enquiries of the national clinical audits
and national confidential enquires which it was eligible to participate in.
The national clinical audits that Surrey and Borders Partnership NHS Foundation Trust was
eligible to participate in during 2010/11 are in the table below.
The national clinical audits that Surrey and Borders Partnership NHS Foundation Trust
participated in, and for which data collection was completed during 2010/11, are listed
below alongside the number of cases submitted to each audit or enquiry as a percentage
of the number of registered cases required by the terms of that audit or enquiry.
National Clinical Audits
Number of Cases
Submitted
% of Registered
Cases
NHS National Mental Health Community Survey 2010 228 28
NHS National Inpatient Mental Health Survey 2010 89 30
National Count Me in Ethnicity Census for England and
464 100
Wales 2010
Infection Control (53 audits completed in services across the
53 40
Trust from April to Dec 2010)
National Patient Safety Survey via South Coast Audit 66 100
National Falls and Bones Audit
1 organisational
100
proforma
completed
National Audit of Occupational Health Management of NHS
29 72
Staff with Depression
National Patient Safety - Prevention of suicide toolkit
general (completed annually - partially completed using
sample - same criteria as ward checklist)
Ongoing
Ongoing
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National Patient Safety ward checklist (choose a sample of 5
patients at high risk of suicide or self harm and who had an
admission and were in hospital at least 48 hours. Sometimes
ward returns are lower if there have been no high risk
patients for the period)
National Continence Audit - bowel and urinary continence
problems
Ongoing
Ongoing
53 66
The reports of nine national clinical audits have been reviewed to date by Surrey and
Borders Partnership NHS Foundation Trust in 2010/11. All clinical audits carried out within
the Trust have recommendations, which are implemented through detailed action plans.
These are monitored through various governance committees to ensure the Trust delivers
quality services.
The reports of 36 local clinical audits were reviewed by Surrey and Borders Partnership
NHS Foundation Trust in 2010/11. A number of recommendations have been borne out of
the results of the audits, which are implemented through detailed action plans. These are
monitored through various governance committees to ensure the Trust delivers quality
services.
Quality Improvement Programmes
Below is a summary of the Trust’s participation in quality improvement programmes
managed by the College Centre for Quality Improvement (CCQI) during the year.
CCQI Programme Trust Participation National Participation
Service accreditation programmes
Electro-convulsive therapy clinics 1 clinic 113 clinics
Working age adult wards 2 wards 158 wards
Psychiatric intensive care units 2 units 36 units
Older people’s mental health wards 0 wards 62 wards
Inpatient learning disability units 3 units 34 units
Inpatient rehabilitation units 0 units 15 units
Memory services 0 services 46 services
Psychiatric liaison teams 0 teams 33 teams
Service quality improvement networks
Inpatient child and adolescent units 0 unit 100 units
Child and adolescent community mental health teams 2 teams 72 teams
Therapeutic communities 0 communities 95 communities
Forensic mental health services 0 services 67 services
Perinatal mental health inpatient units 0 units 15 units
Multisource feedback for psychiatrists (ACP 360) 1 enrolment 3,679 enrolments
Participation in Clinical Research
The number of patients receiving NHS services provided or sub contracted by Surrey and
Borders Partnership NHS Foundation Trust that were recruited during that period to
participate in research approved by a Research Ethics Committee was 98.
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Surrey and Borders has developed its research portfolio substantially over the last year
and is pleased to have been commended by the local research networks for its
participant recruitment levels and response times for NHS National Portfolio studies. We
are collaborating in significantly more NHS National Portfolio studies this year and our
research portfolio is more diverse.
■ The number of NHS National Portfolio studies with which Surrey and Borders is
collaborating as a participating site increased this year
■ In 2009/10 there were 10 studies, six of which have now been completed
■ During 2010/11, the Trust has been involved with 19 studies, of which eight were
newly opened to the Trust in the last three months. The studies have included both
clinical studies directly involving patients receiving services and studies of staff and
organisational factors which affect quality and risk in health care delivery. We
maintain robust procedures to ensure all studies have ethics approval and central
and local NHS authorisations
■ We have a further seven studies awaiting activation following the completion of
necessary authorisations by the NHS nationally and by the Trust locally
■ The Surrey & Sussex Comprehensive Local Research Network has funded
investigator and research support sessions to increase research capability within the
Trust in 2010/11. This funding has supported the increase in research activity and
participant recruitments to studies
■ There have been 379 completed recruitments to National Portfolio studies in
2010/11 at year end, placing the Trust ahead of its target
Use of the Commissioning for Quality & Innovation (CQUIN) Payment Framework 2010/11
A proportion of Surrey and Borders Partnership NHS Foundation Trust’s income in 2010/11
was conditional upon achieving quality improvement and innovation goals agreed between
Surrey and Borders Partnership NHS Foundation Trust and any person or body they
entered into a contract, agreement or arrangement with for the provision of NHS services,
through the Commissioning for Quality and Innovation payment framework. Further
details of the agreed goals for 2010/11 and for the following 12 month period are available
online at: http://www.monitornhsft.gov.uk/sites/all/modules/fckeditor/plugins/
ktbrowser/openTKFile.php?id=3275
The Trust has agreed eight CQUIN indicators with the main NHS Commissioners which are
monitored at the NHS contract meetings and internally at the Executive Board. These
indicators included the following:
■ Improving physical health
■ Serious untoward incident closure and learning
■ Improved patient experience
■ Adoption of outcome measurements and preparation for Payment by Results
■ Children and young people’s skill development
■ Dementia pathway
■ Pathway for people with a learning disability
■ Enhancing quality dementia programme
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The monetary total for the amount of income in 2010/11 conditional upon achieving
quality improvement and innovation goals was £1,500,000. The Trust achieved the
majority of the CQUIN targets and as a result the monetary total for the associated
payment received by The Trust in 2010/11 was £1,267,976.
The above CQUINs are consistent with local and regional strategies.
Registration
Surrey and Borders Partnership NHS Foundation Trust is required to register with the Care
Quality Commission and its current registration status is registered without conditions.
The Care Quality Commission has not taken enforcement action against Surrey and
Borders Partnership NHS Foundation Trust during 2010/11. Surrey and Borders Partnership
NHS Foundation Trust had both its conditions lifted following a comprehensive inspection
by the Care Quality Commission.
Surrey and Borders Partnership NHS Foundation Trust has not participated in any special
reviews or investigations by the Care Quality Commission during the reporting period.
Surrey and Borders has 43 registered locations as of April 2011.
Quality of Data
Surrey and Borders submitted records during 2010/11 to the Mental Health Minimum
Dataset. The percentage of records in the latest published data:
■ Which included the patient’s valid NHS Number was: 99.77 percent
■ Which included the patient’s valid General Practitioner Registration Code was:
99.88 percent
■ Overall Mental Health Minimum Dataset submission was 99.95 percent
Information Governance
Surrey and Borders Partnership NHS Foundation Trust’s Information Governance
Assessment Report overall score and grade for 2010/11 were as follows:
■ The Trust submitted the final information governance toolkit entry on 24 March
2011, achieving a final score of 57 percent. Of the 22 key requirements the Trust
achieved level 2 on 18 requirements, which is grade Green, and level 1 on four
requirements, which is grade Amber.
Surrey and Borders Partnership NHS Foundation Trust will be taking the following actions
to improve data quality in the four requirements not achieved:
■ Requirement 110 - Appropriate contract clauses detailing information governance
requirements have been included and formally agreed to in all contracts and
agreements
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■ Requirement 305 - All Information asset officers have ensured that there are
approved access controls in place for each key information asset under their control
and that access to those assets is only possible for individuals who have been duly
authorised
■ Requirement 313 - Controls and procedures have been implemented for all IT
networks and publicised to staff. Staff need to have been informed of their
responsibilities
■ Requirement 323 - All mandatory safeguards are in place to protect the information
assets that hold identifiable data and risk assessments need to have been carried
out to see if the safeguards are sufficient
Payment by Results
Surrey and Borders Partnership NHS Foundation Trust was not subject to the Payment by
Results clinical coding audit during the reporting period by the Audit Commission.
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Other Information
Overview of Quality Performance against Trust Indicators in 2010/11
In the reporting year the Board brought together its performance monitoring against
national targets with its agreed safety indicators to form a Quality Service Performance
Report. This follows a balanced scorecard framework based on the Trust’s Vision and
Values.
The Board’s agreed indicators were informed through discussions with staff, people who
use services, carers, commissioners and other stakeholders and formed part of the Quality
Improvement Plan. Details of the Trust’s performance against its key indicators are
provided below.
Patient Safety
Care Programme Approach (CPA) 7-Day Follow Up
This is the percentage of people under adult mental illness specialties on enhanced CPA
who were seen/contacted within seven days of discharge from hospital.
Quarter
The Number of People
Discharged From Hospital
on Enhanced CPA
The Number of People on
CPA Seen/Contacted
Within 7 Days of
Discharge From Hospital
Percentage of
Patients
Contacted
Percentage
Threshold
2009/10 Q1 160 157 98% 95%
Q2 158 155 98% 95%
Q3 127 126 99% 95%
Q4 89 88 99% 95%
Total 534 526 99% 95%
2010/11 Q1 157 154 98% 95%
Q2 150 148 99% 95%
Q3 128 126 98% 95%
Q4 147 143 97% 95%
Total 582 571 98% 95%
Data source: Internal monthly collection and the Care Quality Commission – special data
collection during the 2010/11 financial year. Reported to Executive Board through the
Trust Service Quality Performance Report. This information is governed by standard
national definitions and it has been chosen for the Quality Accounts because it is part of
the Trust Vision and Values to ‘Treat People Well’.
Absent Without Leave (AWOL)
This is the number of people who are reported absent without leave from inpatient
services. The information is reported to the Trust Executive Board and Quality Committee
at regular intervals. The Trust ensures that those areas showing signs of increased AWOLs,
are monitored and managed through the local Quality Action Groups to ensure that
effective measures are implemented to reduce re-occurrence and minimise the possibility
of trends developing. The Trust works closely with key stakeholders to ensure that patients
who go AWOL are sufficiently supported to facilitate their return to the ward environment.
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30
20
10
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actual 2009/10 2 6 4 3 25 13 10 9 8 3 7 10
Actual 2010/11 9 8 7 24 24 4 11 6 13 13
Threshold 5 5 5 5 5 5 5 5 5 5 5 5
Data source: Internal monthly collection from ward areas. This is reported to the Executive
Board through the Trust Service Quality Performance Report. This information is not
governed by standard national definitions and it has been chosen because it provides the
Trust with a suitable comparison of our yearly performance on the rate of absent without
leave cases.
Serious Untoward Incidents
The Trust pays close attention to serious incidents; these include unexpected deaths,
detained patients who are absent without leave, breaches in mixed sex accommodation,
serious deliberate self harm and other serious and concerning events.
Serious incidents requiring investigation are monitored on a monthly basis by the
Executive Board and are reported regularly to the Trust Board and the Council of
Governors. In 2010 there was an increase in unexpected deaths of people using our
services. This has been carefully analysed by a senior clinical review team and has been
shared with the Trust Board, the Executive Directors and the Trust’s lead commissioner.
The results of the analysis show that, although each individual unexpected death is a tragic
event, we are consistent with national trends (National Confidential Inquiry into suicide
and homicide by people with mental illness, Annual Report July 2010). The Trust is
currently participating in a three-year retrospective review of unexpected deaths across
the South East Coast Strategic Health Authority to ensure that there is a robust and
reflective approach to all these incidents.
The Trust has in place robust processes to investigate and monitor trends to support
learning from such incidents. We work closely with our commissioners to ensure the
quality of our investigations is of a high standard to enable the effective identification of
the root causes to prevent reoccurrence. We have set a clinical priority in the Trust’s
Annual Plan 2011/2012 around serious incidents, particularly around completion of action
plans coming from incident investigations to ensure safer services.
Page 55 of 132

10
8
6
4
2
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actual 2008/09 2 6 3 7 3 9 9 5 6 8 5 3
Actual 2009/10 3 2 3 1 2 1 2 1 2 7 2 4
Actual 2010/11 6 9 6 6 8 2 5 9 5 9 6 8
Threshold 5 5 5 5 5 5 5 5 5 5 5 5
Data source: Steis (Strategic Executive Information System) managed by the Department
of Health. This information is reported to the Executive Board through the Trust Service
Quality Performance Report. This information is governed by standard national definitions
and it has been chosen for the Quality Accounts because it provides important information
on the rates of serious incidents reported on Steis in the organisation.
People with Drug Problems in Effective Treatment
Number of people with drug
problems in effective treatment
Trust Score Threshold Result
0.4539 Less than 1.96 Achieved
New Journey
Starts
Individuals Retained for 12
Weeks or More
Number
Completed
Within 12
Number Retained or Care
Planned Exit Within 12
Weeks
Number % Weeks Number %
April 2009 to March 2010 for Comparison to Reports for March 2011
569 488 86 21 509 86
January 2010 to December 2010 for Comparison to Reports for March 2011
532 445 84 17 462 87
Data source: National Drug Treatment Agency for 2010/11 financial year. This information
is reported to the Executive Board through the Trust Service Quality Performance Report.
This information is governed by standard national definitions and it has been chosen for
the Quality Accounts because it is an example of how the Trust works to ensure that
patients have access to effective treatment.
Page 56 of 132

Clinical Effectiveness
Assertive Outreach
Number of people receiving Assertive Outreach Services
400
300
200
100
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actual 2008/09 209 210 211 214 222 220 230 294 305 306 315 314
Actual 2009/10 320 318 316 320 329 317 322 321 321 307 311 314
Actual 2010/11 319 315 312 307 312 315 314 322 319 319 320 316
Threshold 306 306 306 306 306 306 306 306 306 306 306 306
Data source: Internal data collection. This information is reported to the Executive Board
through the Trust Service Quality Performance Report. This information is not governed by
standard national definitions and it has been chosen for the Quality Accounts because it is
an example of how the Trust works to ensure patients have access to effective treatment.
Early Intervention in Psychosis
Number of new cases referred to the Early Intervention in Psychosis Services.
200
150
100
50
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actual 2008/09 9 18 45 72 89 108 125 130 137 148 155 173
Actual 2009/10 7 16 25 34 39 50 64 76 87 96 106 145
Actual 2010/11 10 26 38 51 68 81 97 114 130 147 161 172
Threshold 11 24 35 48 60 72 84 96 108 121 132 145
Data source: Internal data collection. This information is reported to the Executive Board
through the Trust Service Quality Performance Report. This information is not governed by
standard national definitions and it has been chosen for the Quality Accounts because it is
an example of how the Trust works to ensure that patients have access to effective
treatment.
Page 57 of 132

Home Treatment Team
Number of home treatment episodes.
2000
1500
1000
500
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actual 2008/09 167 326 468 631 780 925 1083 1251 1393 1522 1628 1799
Actual 2009/10 145 308 470 634 783 917 1074 1248 1398 1560 1720 1909
Actual 2010/11 172 310 464 655 810 978 1098 1265 1383 1566 1724 1917
Threshold 129 269 423 581 739 897 1055 1213 1371 1517 1646 1777
Data source: Internal data collection. This information is reported to the Executive Board
through the Trust Service Quality Performance Report. This information is not governed by
standard national definitions and it has been chosen for the Quality Accounts because it is
an example of how the Trust works to ensure patients have access to effective treatment.
Patient Experience
Care Plans
The service user has been given a copy of the current care plan
Month Threshold East Mid North North
West
South
West
EIIP* Total Audit Response
Rate - 24 Teams
April
2010 90% 90% 100% N/A 80% 60% 90% 84%
30% response rate
(7 teams)
May 90% 100% 90% 40% 75% 97% 93% 83%
54% response rate
(13 teams)
June 90% 100% 55% 65% 80% 90% 100% 82%
54% response rate
(13 teams)
July 90% 100% 97% 50% 100% 95% 100% 90%
58% response rate
(14 teams)
Aug 90% 93% 70% 50% 87% 90% 97% 82%
75% response rate
(18 teams)
Sept 90% 90% 73% 50% 80% 100% 95% 81%
54% response rate
(13 teams)
Oct 90% 93% 60% 80% 97% 79% 97% 84%
62% response rate
(15 teams)
Nov 90% 93% 77% 60% 100% 76% 100% 84%
67% response rate
(16 teams)
Dec 90% 95% 55% 70% N/A 75% 95% 78%
42% response rate
(10 teams)
Jan
2011 90% 100% 30% 80% 60% N/A 100% 74%
33% response rate
(8 teams)
Page 58 of 132

Feb 90% 90% 50% 60% N/A N/A 100% 75%
March 90% N/A 70% 60% 60% 70% 100% 72%
* Early Intervention in Psychosis Service
24% response rate
(5 teams)
33% response rate
(8 teams)
Data source: Internal data collection, a monthly manual record keeping audit has been
established within each care group. This information is reported to the Executive Board
through the Trust Service Quality Performance Report. This information is not governed by
standard national definitions and it has been chosen for the Quality Accounts because it is
an example of how the Trust works to ensure that patients are aware of their care and
have access to their care plans.
Delayed Transfers
This data looks at the number of non-acute patients (aged 18 and over) whose transfer of
care was delayed. The delayed transfers of care attributable to social care are excluded. It
is not possible to effectively compare this performance to the 2009/10 data because the
collection format has been changed for 2010/11.
2010/11 Q1 Q2 Q3 Q4
Delayed Transfer of Patients 113 113 113 113
Performance 7% 4% 4% 4%
Threshold – no more than 7.5% 7.5% 7.5% 7.5% 7.5%
Data source: Hospital Episode Statistics (HES) and situation reports. This information is
reported to the Executive Board through the Trust Service Quality Performance Report.
This information is governed by standard national definitions and it has been chosen for
the Quality Accounts because it is an example of how the Trust works to ensure that
patients are aware of their care and have access to their care plans.
User Experience
NHS Community Survey Results
In 2009 the Trust undertook the NHS Community Mental Health Survey although this was
not a national requirement. The results showed that 73 percent of people using the Trust’s
community services rated their care as excellent, very good or good which is comparable
with results from the 2008 survey.
The 2010 survey involved 66 NHS trusts in England (including combined mental health and
social care trusts, foundation trusts and primary care trusts that provide mental health
services). The Care Quality Commission received responses from more than 17,000 service
users, a response rate of 32 percent.
People who use services aged 16 and over were eligible for the survey if they were seen by
the Trust between 1 July 2009 and 30 September 2009 and had received specialist care or
treatment for a mental health condition.
Page 59 of 132

In 2010 the Trust can demonstrate significant improvement compared to the 2009 results,
which highlights the hard work and dedication of Surrey and Borders’ staff. In January 2011
surveys were sent to a sample of 850 people who use Surrey and Borders Community
Mental Health Services and 224 responses were received.
Questions were asked about medication; talking therapies; care co-ordinators; care plans;
care reviews; day-to-day living; crisis care and overall service user satisfaction and the
results compared with other trusts nationwide.
Benchmarking
Results showed that we were in the intermediate range of all trusts in the majority of the
standards. However, we were in the top performing trusts in the country for the following
areas:
1. Involving a service user’s family or someone close to them
2. Individual’s views taken into account when deciding what is in the care plan
3. Day to day living for care responsibilities and finding work
Other areas have shown significant improvement from the last survey too with people who
use services having more trust and confidence in our health and social care workers;
feeling more listened to and being happier with the help they receive in getting benefits.
Further, the overall satisfaction of the Trust’s community services for them being excellent
or very good has risen from 50 percent to 59 percent. This equated to a benchmarking
score of 7.2 which put us at “about the same as other trusts”.
The Trust queried this with the Care Quality Commission as other trusts had achieved
“better than average” with the same score. The Care Quality Commission responded
accordingly:
The reason that Surrey and Borders does not achieve “better than average” is essentially due
to confidence. The response rate for Surrey and Borders was lower than for the other trusts
and therefore there were less respondents to the questions. The greater the number of
respondents, the greater the certainty surrounding the mean result and vice versa. Therefore
two trusts with the same score might fall into different bands if one has less reliable data
(that is, had fewer respondents).
Of the 66 trusts that were surveyed 40 were rated “significantly worse than average” in one
or more questions. Surrey and Borders was not rated below average in any area.
Data source: NHS Community Mental Health Survey. This is national data that is governed
by standard national definitions and it is reported to the Trust Executive Board through the
Quality Report. The indicator has been chosen for the quality accounts because it provides
information that allows for effective national benchmarking.
Page 60 of 132

NHS Inpatient Service User Survey 2010
Service User Experience
Inpatient Survey 2009
30
20
10
0
Excellent Very Good Good Fair Poor Very Poor
2009 20 22 22 16 20 0
In the 2009 NHS Inpatient Service User Survey, 65 percent of people using the Trust’s
inpatient services rated their care as excellent, very good or good. The Trust had already
implemented a number of improvements at the time the findings were published including
the launch of the mental health crisis helpline. The findings also underline the importance
of pressing ahead with our plans to develop assessment and treatment hospital services
across Surrey and North East Hampshire.
An action plan has been developed to address the specific issues arising from the survey, in
particular: the Trust is undertaking a review of the inpatient nursing resource to look at
ways of enhancing patient care; a review of ward rounds has been undertaken to maximise
opportunities for patients to meet with psychiatrists to improve communications; the
medications management policy has been updated to involve people in managing their
medicines; and all patients are followed up within seven days of discharge and this is
monitored through the Care Programme Approach.
Inpatient Survey 2010
40
30
20
10
0
Excellent Very Good Good Fair Poor Very Poor
2010 18 37 21 12 12 0
In the 2010 NHS Inpatient Service User Survey, 76 percent of people using the Trust’s
inpatient services rated their care as excellent, very good or good.
Data source: NHS Inpatient Service User Survey. This is reported to the Executive Board
through the Quality Report. This is national data that is governed by standard national
definitions and the indicator has been chosen for the Quality Accounts because it
provides information that allows for effective national benchmarking.
Page 61 of 132

Expert Report – Integrated Experience Report
The Trust has developed the expert report as a vehicle for bringing together information
and sharing direct feedback from people who use our services and their carers including
feedback from external scrutiny, objective observation and other feedback from the
communities we serve. These include the following data sources:
a) Summary of compliments
b) Summary of complaints
c) Feedback from Patient Advice and Liaison Service (PALS)
d) Patient experience trackers
e) Carers update
f) National inpatient survey
g) National community survey
h) Periodic service review
i) Board walk-arounds
j) FoCUS (Forum of Carers and people who Use Services)
k) Surrey Local Involvement Network (LINk) feedback
l) NHS Surrey feedback
m) Mental Health Act Managers report
n) Care Quality Commission visits
o) Annual Care Quality Commission/Mental Health Act Commission report
p) Feedback or experience from the communities we serve
This is a quarterly report that is shared widely both within and outside the Trust. A scoping
exercise has been undertaken with people who use services and carers to ensure the
report captures relevant information in a format that is appropriate. This will help develop
the document further.
Data source: Internal data. This information is regularly reported to the Executive Board
through the Quality Report and Risk & Safety Report. This is national data that is governed
by standard national definitions and the indicator has been chosen for the Quality
Accounts because it provides information that allows for effective national benchmarking.
Page 62 of 132

Annex to the Quality Account
The Quality Account has been designed and written following discussions regarding the
quality of our services throughout the year with our Board, the clinical teams and key
stakeholders. These include the Forum of Carers and people who Use Services (FoCUS), our
Foundation Trust Governors, NHS Surrey and the Care Quality Commission.
NHS Surrey has had the opportunity to review this account prior to publication and has
provided the following statement:
Response by the Commissioning Primary Care Trust
NHS Surrey has reviewed Surrey and Borders Partnership NHS Foundation Trust Quality
Account and confirms it meets the legal requirements in relation to the form and content
expected of a Quality Account. This Quality Account could be improved by sharing findings of
some of the clinical audits which have been undertaken and making clearer Surrey and
Borders’ commitment to research as a driver for improving the quality of care and patient
experience. This could have been verified by demonstrating how clinical staff stay abreast of
the latest possible treatments/clinical interventions and the reporting of any formal
publications of research conducted by staff.
NHS Surrey is pleased to commend Surrey and Borders on their ward to Board approach of
ensuring that quality and patient experience within their service is of a good quality. NHS
Surrey supports Surrey and Borders’ statement that internal and external examination of
their services on a routine basis can be clearly demonstrated.
NHS Surrey was concerned that during the early part of 2010 the Care Quality Commission
applied conditions to registration, however the action taken to address these areas of
concern was exemplary and is also to be commended.
NHS Surrey would encourage Surrey and Borders to continue their focus on more timely
closure of serious incidents and addressing concerns raised by services users through
surveys and direct feedback.
Jo-anne Bradford
Consultant Public Health, NHS Surrey
1 June 2011
Surrey Local Involvement Network (LINk) has also had the opportunity to review this
account prior to publication and has provided the following statement:
Response by Surrey LINk
The following comment has been generated by multiple LINk members and collated by Jane
Owens, LINk volunteer and Learning Disabilities Lead, on behalf of the LINk Mental Health &
Learning Disabilities Group.
Concerns have been raised about the limited time given to read and comment on the
account. Volunteers had only 4 days to respond, over a Bank holiday period and the initial
version of the account was not complete.
Page 63 of 132

The first reference to the LINk on Page 62 should be written initially in full as ‘The Surrey
Local Involvement Network’. Further references should be written as ‘The Surrey LINk’ or
‘LINk’.
The response and involvement of carers, though laudable, should not take precedence
over the response and involvement of service users when possible (mentioned twice in that
order).
Communication at what ever level or method is essential in a Trust whose business is
helping those either with mental health difficulties or a learning disability but no mention is
made in the report of the number of units which are accessible and have hearing loops.
Furthermore, no mention is made in regard to accessible information and/or literature and
whether it is up to date. For example; menus, available in many Learning Disability units.
Last year the report clearly identified areas where specific improvement had been
achieved to the experience of the service user. This appears absent in this year’s report.
Why?
No mention of the quality and variety of food is made. No indication is given in regard to
the ‘five a day’ requirement and whether it is met or not.
No detail on Improved Fitness Outcomes and whether they are measured or not.
(Research shows that improved physical fitness has beneficial effect in mental health service
users and those with dementia.)
The quality of Personal Centred Plans, Health Action Plans and GP health checks were not
mentioned. These are essential when planning care when moving.
Periodic Service Review gives limited information on the specific impact of the
improvement for the service users.
LINk volunteers have expressed disappointment that there is no mention of the Crisis Line
Audit and the action plan. Major concerns have been expressed by service users and their
carers with this service.
The Surrey LINk Learning Disabilities Group have carried out Enter and View visits during the
reported period to: Ethel Bailey /Oak glade NHS Campus and April Cottage, Treatment and
Assessment Unit and made the following observations:
Four Homes at Ethel Bailey, NHS Campus (the other two homes visited by NHS Surrey):
Person Centred Plans and Health Action Plans have definitely improved and are now
personal to the individuals, though it is of paramount importance that they are kept under
review, particularly as they prepare to move to new provision. There are also improved
activities for the residents.
April Cottage: Now offering a Treatment and Assessment service with clients accessing
the service for shorter time and care managers involved with discharge plans commencing
on admission. Also a robust transition process has been established prior to discharge with
the involvement of community teams. However, environment issues need to be managed
proactively and kept under constant review, the location does not allow easy access for
relatives especially those from West Surrey.
Page 64 of 132

Statement of Directors’ Responsibilities in Respect of
the Quality Account
The Directors are required under the Health Act 2009, National Health Service (Quality
Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment
Regulation 2011 to prepare Quality Accounts for each financial year. The Department of
Health has issued guidance on the form and content of annual Quality Accounts (which
incorporate the above legal requirements).
In preparing the Quality Account, 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 2010/11
■ The content of the Quality Report is not inconsistent with internal and external
sources of information including:
­ Board minutes and papers for the period April 2010 to June 2011
­ Papers relating to quality reported to the Board over the period April 2010 to
June 2011
­ Feedback for the commissioners dated 01/06/2011
­ Feedback for Governors dated 09/03/2011
­ Feedback from Surrey LINk dated 10/05/2011
­ The Trust’s complaints report published under regulation 18 of the Local
authority social services and NHS Complaints Regulations 2009, dated
18/04/11
­ The 2010 NHS Inpatient survey
­ The 2010 NHS Staff Survey
­ The Head of Internal Audit’s annual opinion over the Trust’s control
environment dated 01/06/2011
■ The Quality Accounts present 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, is subject to appropriate scrutiny and review; and the Quality
Account has been prepared in accordance with Department of Health guidance and
with Monitor’s annual reporting guidance (which incorporates the Quality Accounts
regulations) (published at www.monitor-nhsft.gov.uk/annualreportingmanual) as
well as the standards to support data quality for the preparation of the Quality
Report (available at www.monitor-nhsft.gov.uk/annualreportingmanual).
Page 65 of 132

The Directors confirm to the best of their knowledge and belief they have complied with
the above requirements in preparing the Quality Account.
By order of the Board
Date: 6 June 2011 Signed: Chairman
Date: 6 June 2011 Signed: Chief Executive
Page 66 of 132

Independent Auditors Report in Respect of the Annual Quality Report
Draft Independent Auditor’s Report to the Council of Governors of Surrey and Borders
Partnership NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Surrey and Borders Partnership NHS
Foundation Trust to perform an independent assurance engagement in respect of the
content of Surrey and Borders Partnership NHS Foundation Trust’s Quality Report for the
year ended 31 March 2011 (the “Quality Report”).
Scope and Subject Matter
We read the Quality Report and considered whether it addresses the content
requirements of the NHS Foundation Trust Annual Reporting Manual, and considered the
implications for our report if we become aware of any material omissions.
Respective Responsibilities of the Directors and Auditors
The Directors are responsible for the content and preparation of the Quality Report in
accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual
2010/11 issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on
whether anything has come to our attention that causes us to believe that the content of
the Quality Report is not in accordance with the NHS Foundation Trust Annual Reporting
Manual or is inconsistent with the documents.
We read the other information contained in the Quality Report and considered whether it
is materially inconsistent with the following:
■ Board minutes for the period April 2010 to June 2011
■ Papers relating to quality reported to the Board over the period April 2010 to June
2011
■ Feedback for the commissioners dated 01/06/2011
■ Feedback for governors dated April 2010 to March 2011
■ Feedback from Surrey LINk dated April 2010 to June 2011
■ The Trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, dated 18/04/11
■ The 2010 NHS Inpatient Survey
■ The 2010 NHS Staff Survey
■ The Head of Internal Audit’s annual opinion over the Trust’s control environment
dated 01/06/2011
■ CQC quality and risk profiles dated September 2010 to April 2011
We considered the implications for our report if we became aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
Page 67 of 132

This report, including the conclusion, has been prepared solely for the Council of
Governors of Surrey and Borders Partnership NHS Foundation Trust as a body, to assist the
Council of Governors in reporting Surrey and Borders Partnership 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 2011, to enable the Council of Governors
to demonstrate they have discharged their governance responsibilities by commissioning
an independent assurance report in connection with the Quality Report. To the fullest
extent permitted by law, we do not accept or assume responsibility to anyone other than
the Council of Governors as a body and Surrey and Borders Partnership NHS Foundation
Trust for our work or this report save where terms are expressly agreed and with our prior
consent in writing.
Assurance Work Performed
We conducted this limited assurance engagement in accordance with International
Standard on Assurance Engagements 3000 (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:
■ Making enquiries of management
■ Comparing the content requirements of the NHS Foundation Trust Annual Reporting
Manual to the categories reported in the Quality Report; and
■ Reading the documents
A limited assurance engagement is less in scope than a reasonable assurance engagement.
The nature, timing and extent of procedures for gathering sufficient appropriate evidence
are deliberately limited relative to a reasonable assurance engagement.
Limitations
It is important to read the Quality Report in the context of the criteria set out in the NHS
Foundation Trust Annual Reporting Manual.
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 2011, the content of the Quality Report is not
in accordance with the NHS Foundation Trust Annual Reporting Manual.
Darren Wells
Officer of the Audit Commission
Audit Commission
2nd Floor, The Agora
Ellen Street, Hove BN3 3LN
6 June 2011
Page 68 of 132

Corporate Governance and
Board of Directors
Surrey and Borders has seven Non Executive Directors including the Chairman and six
Executive Directors including the Chief Executive, who attend the Trust Board. Two
additional Executive Directors attend Board meetings on a regular basis. The Board of
Directors is responsible for the management of the Trust and for ensuring corporate
governance, performance and operational standards are upheld. Risks to the Trust’s
delivery of its strategic objectives are monitored through a Board Assurance Framework
which identifies the controls, the gaps in the controls, where assurances can be found and
the gaps in assurances. Surrey and Borders complies with the provisions of the NHS
Foundation Trust Code of Governance.
The performance of the Executive Directors is managed through the Trust’s Appraisal and
Supervision Policy and is reported for discussion at the Remuneration and Terms of Service
Committee. The Council of Governors appoints a Nominations Committee which
undertakes the same function of performance evaluation for the Non Executive Directors.
The Board of Directors is held to account by the Council of Governors.
The Board of Directors consults on its future strategy and develops its annual plans with
the close involvement of its Council of Governors. Twice yearly joint workshops with the
Board and Governors are held to reflect on progress against plans and to discuss priorities
for the coming year. The key role of the Council of Governors is to influence the strategic
direction of the Trust taking into account the needs and views of the members,
stakeholders and partners. During the past year the Council of Governors appointed a new
Chairman and one Non Executive Director Audit Chair. The Council also approved the
appointment of the Trust’s auditors.
The Board took the decision at its Board meeting on 24 March 2010 to return to public
Trust Board meetings and to hold at least four public Trust Board meetings a year in
addition to the four Council of Governors meetings. Commercially sensitive information
will remain in Board meetings held in private.
The membership of the Board of Directors will continue to be regularly reviewed by the
Board of Directors and members of the Nominations Committee, which includes Trust
Governors, to ensure that it is well balanced and covers the full range of expertise required
by a Foundation Trust. Through self-assessment, the Board believes that it currently has a
good mix of commercial and financial knowledge, management and clinical experience,
public sector expertise and community engagement.
Page 69 of 132

Non Executive Directors
Richard Greenhalgh, Chairman
Appointed in February 2011, term of office 3 years. Chairman of Care
International UK and member of the global board, Chairman of the
Council for Industry and Higher Education, and board member of the
British Youth Opera. His current business interests include Senior
Independent Director and Chair of the Remuneration Committee with
Rank Group PLC and member of the advisory board of Liaison Financial
Services Ltd and Just Accounts Ltd. He is also on the advisory committee of the Financial
Reporting Council. Former Chairman of Unilever UK. He is a fellow of Green Templeton
College Oxford and RSA, IOD and CMI. Qualifications: MA in Social Anthropology,
Cambridge University
Roshan Bailey, Non Executive Director
Appointed in April 2005, term of office 4 years renewed in April 2009 for
a further 3 years. Interim Chairman 14 July 2010 to 15 February 2011.
Chair of Remuneration and Terms of Service Committee. Director of
Project Action Ltd. Employment Tribunal Member (since October 2005).
Trustee of the Mary Frances Trust (since March 2000), Trustee of
HEADWAY Surrey (June 1995 – October 2009, Chairman from 2000 –
2005). Director of Surrey Supported Employment (since October 2006), Prince’s Trust
Business Panel member 1994 – 2010. Prior experience includes senior management in BT
and Managing Director of Surrey Business Network. Qualifications: MA Oxon in Politics,
Philosophy & Economics
John Banfield, Non Executive Director
Appointed in April 2005, term of office 4 years renewed in April 2009 for
a further 18 months and in September 2010 renewed again until
replacement is appointed. Formerly Non Executive Director of Surrey
Oaklands NHS Trust. Thirty year international career with a major multinational
oil company, latterly as Chairman of Mobil Oil Ltd (1994 – 1996)
and Vice President of Mobil Europe (1996 – 2001). Fellow of the Energy
Institute. Qualifications: MA Cantab
Della Fallon, Senior Independent Director
Appointed in June 2005, term of office 4 years renewed in June 2009 for
a further 3 years. Chair of Quality Committee from November 2009.
Appointed Senior Independent Director in May 2010. Worked in the NHS
and Local Government in a variety of roles including as a commissioner of
mental health services and an adviser to the Department of Health on the
health needs of vulnerable children. Founder member of the Patient and
Public Involvement Forum for the former North West Surrey Partnership NHS Trust. Chair
of the Trust’s Mental Health Act Managers until January 2010. Currently working as a
management consultant and as a lay chair for Kent, Surrey and Sussex Deanery
Qualifications: BA (Hons) Psychology, Newcastle University; MBA, Leicester University
Page 70 of 132

Peter Harrison, Non Executive Director
Appointed in October 2008, term of office 3 years. Currently Director of
Sales and Solutions, Siemens Healthcare - responsible for diagnostic
imaging sales and product management activities within the UK. Director
and Chair of Metier Healthcare from 2002 – 2008. Chair of AXrEM, (the
Association of Healthcare Technology Providers for Imaging,
Radiotherapy and Care), 2007 and 2008. Member of the Clinical
Radiology Faculty Board of the Royal College of Radiologists, (2009). Prior to joining
Siemens Healthcare, Peter held general management, sales and technical management
positions within the business services and IT sectors, both within Siemens companies and
Thorn EMI. Qualifications: BSc (Electrical and Electronic Engineering)
Barry Rourke, Non Executive Director
Appointed in June 2005, term of office 4 years renewed in June 2009 for
a further 3 years. Chair of Audit Committee from October 2007 until 31
March 2011. Audit and business advisory partner with
PricewaterhouseCoopers from 1984 – 2001. Independent member of
the audit committee for the Department for Energy and Climate Change.
Independent non executive director of 3Legs Resources PLC, an
independent oil and gas exploration and development company, New World Resources
NV, Avocet Mining PLC and Ruukki Group PLC. Qualifications: Fellow of the Institute of
Chartered Accountants in England and Wales
Richard Vause, Non Executive Director
Appointed in June 2006, term of office 4 years renewed in May 2010 for
a further 3 years. Previously Non Executive Director with West Sussex
Health & Social Care NHS Trust. Richard is currently a Mental Health Act
Manager, Chair of the Surrey Group of Mental Health Act Managers and
Chair of the Equality and Human Rights Committee. Lay Chair of Kent,
Surrey and Sussex Post Graduate Medical Deanery. A career banker, was
Corporate Actions & Banking Director of Lloyds TSB Registrars from 1990 to 2002.
Qualifications: Fellow of the Chartered Institute of Bankers, Diploma in Financial Studies
and Fellow of the Industry & Parliament Trust
Page 71 of 132

Executive Directors
Fiona Edwards, Chief Executive
Appointed to post in April 2005 and Chief Executive-designate since
November 2004. For the previous four years Fiona was Chief Executive
of Surrey Hampshire Borders NHS Trust. Her health service career began
in 1994 at West Berkshire Priority Care Services NHS Trust where she
was Executive Director responsible for Human Resources and major
change programmes. Fiona’s private sector career spanned 10 years
within the manufacturing sector as a human resources professional (within the Allied
Lyons Group) and latterly Director of Human Resources for a medium sized manufacturing
company (ACCO Rexel Ltd). Qualifications: MA in English (St Andrews) and post-graduate
professional qualifications in Personnel Management. INSEAD Advanced General
Management
Clive Field, Director of Finance
Appointed to post in July 2010. Director of Finance & Performance for
Berkshire Healthcare NHS Foundation Trust from January 2004 – June
2010. Director of Finance at the Royal Berkshire & Battle Hospitals NHS
Trust from May 2001 – Jan 2004, having previously held post as Head of
Financial Management June 1997 – May 2001. Clive started in the NHS in
September 1988 working at King’s College Hospital, London holding
various posts in the Finance Department before joining Mid Sussex NHS Trust in December
1995 as the Head of Management Accounting. Qualifications: ACMA, BSc in Biochemistry
Dr Rachel Hennessy, Medical Director
Appointed Medical Director in February 2011 following a period as
interim Medical Director and 5 years as Deputy Medical Director with
Surrey and Borders. Previously worked in a variety of medical
management roles including Medical Director at North West Surrey
Mental Health Partnership Trust from 2002 – 2005. She was appointed
as a Consultant Psychiatrist in 1995. Qualifications: MB ChB from
Leicester University and completed her psychiatric training on the St Georges rotation.
Rachel was awarded Fellowship of the Royal College of Psychiatrists (FRC Psych) in 2010
Pat Keeling, Director of Strategic Change
Appointed to post in April 2005 and voting Board member in June 2010.
Following a clinical career as a chartered physiotherapist she has held a
range of senior management roles in specialist, community and
commissioning organisations. Over the past ten years Pat’s roles have
included Director of Business Development, Director of Locality Services
and Director of Planning. Pat is an alumnus of the Medical Architecture
Research Unit and was awarded the Course Director’s Prize 2006 for her innovative
approach to leadership of sustainable development. Qualifications: MCSP, BSc in Research
Methodology, MSc (Dist) in Planning Buildings for Health
Page 72 of 132

Mandy Stevens, Director of Quality and Performance (Nurse Director)
Appointed to post in January 2010. Mandy started her career in
healthcare as a Nursing Assistant at Brookwood hospital aged 17. Since
completing her training in mental health nursing in 1992, Mandy has
worked across a variety of healthcare settings in mental health, including
eight years of community nursing on the Crisis Response Team and as a
Community Psychiatric Nurse. Mandy became Modern Matron for one
of our predecessor trusts in 2004 before joining Priory Healthcare as a Hospital Director for
forensic hospitals in 2006. Qualifications: RN(MH)
Jo Young, Director of Operations
Appointed to post in March 2007. Director of Loddon Alliance, the social
care arm of Surrey Hampshire Borders, before being made Interim
Operations Director in 2001. Appointed Director of Learning Disability
services for Surrey and Borders in April 2005. Jo’s NHS career began in
1980 and she completed her training as a Registered Nurse for People
with Learning Disabilities in 1987 at Southampton University School of
Nursing. While Jo was working at Loddon NHS Trust in North Hampshire she completed her
MSc. Qualifications: RN(LD); MSc, Applied Psychology; HNC Business Management; HND
Business Management; BA (First Class Hons) Business Studies
Terms of office for Non Executive Directors may be ended by resolution of the Council of
Governors following a procedure laid down in the Foundation Trust’s constitution.
Accounting policies for pensions and other retirement benefits are set out in note 1.3 to
the accounts. Details of senior employees’ remuneration can be found in page 83 of the
remuneration report.
Page 73 of 132

Trust Governance Committees
Name
Board
11 meetings
Audit
Committee
4 meetings
Non Executive Directors
Remuneration
Committee
3 meetings
Nomination
Committee
7 meetings
Graham Cawsey 4 1 1
Richard Greenhalgh 1 1 1
Roshan Bailey 2 10 2 3
John Banfield 7 4 2 4
Della Fallon 9 4 3 5
Peter Harrison 9 3 2
Barry Rourke 3 8 4 3
Richard Vause 8 2 2
Fiona Edwards 11
Clive Field 6
Ann Harrison 4
Rachel Hennessy 9
Pat Keeling 8
Alison McKay
Mandy Stevens 11
Jo Young 9
Executive Directors
Governors
Sally Brady (Lead) 7
Stuart Craig (Deputy Lead) 7
Maurice Brook 7
Mike Smith 3
1 The Trust Chairman is the Chair of the Nomination Committee. The Trust’s Senior Independent Director
took on this post between June 2010 – February 2011
2 Roshan Bailey during her tenure as Interim Chairman ceased to attend the Audit Committee in
accordance with the terms of reference
3 Barry Rourke is the Chair of the Audit Committee
The Trust’s governance committees provide assurance and focus to key work programmes
for the Board during the year. The Trust Board keeps its governance arrangements under
constant review to ensure they remain fit for purpose. A formal review is undertaken at
least on an annual basis.
Audit Committee
The Audit Committee is charged with monitoring the effectiveness of the Trust’s activities,
controls and assurance processes of financial control and to bring to the Executive Board
any items of concern. This effectiveness can be described in five broad categories of
integrated governance, performance, controls, value for money and probity.
Page 74 of 132

Nomination Committee
The Nomination Committee advises the Trust Board about appropriate appointment and
remuneration for the Non Executive Directors. In relation to the remuneration and terms
of appointment for the Chairman and Non Executive Directors, recommendations are
made to the Trust Board and then the Council of Governors to ensure they are in line with
the Trust’s reward strategy. The Committee also receives reports on behalf of the Council
of Governors on the process and outcome of the appraisal for the Chairman and Non
Executive Directors.
Register of Interests
Surrey and Borders Partnership NHS Foundation Trust maintains a Register of Interests
that is open to the public through the Trust’s Associate Director of Governance, Lynn
Fairfield, on telephone: 01372 204056 or email: lynn.fairfield@sabp.nhs.uk.
Sarah Amani, Employee of the Year runner-up
Page 75 of 132

Council of Governors
The Council has 39 Governors, 28 of whom are elected. These are made up from the
following constituencies:
All Governors are elected for a three-year period. They can hold office for up to nine years
subject to being re-elected after each three years.
In May 2011 the Trust reached its third anniversary as a Foundation Trust, which means
that for the majority of governors their term of office is came to an end. Therefore, we
commenced an election engagement programme in February 2011 to encourage members
to stand for election to the Council of Governors. The election process was concluded on 1
May 2011. There were a number of vacant seats arising through the year which were held
as vacancies due to the forthcoming elections:
■ Public constituency, Surrey
■ Public constituency, people who use other services
■ Public constituency, learning disabilities
■ Public constituency, carers and family (2 seats)
■ Staff constituency, care and social care assistants
■ Staff constituency, social workers
Register of Interests
Surrey and Borders Partnership NHS Foundation Trust maintains a Register of Interests for
Governors that is open to the public through the Trust’s Associate Director of Governance,
Lynn Fairfield on telephone: 01372 204056 or email: lynn.fairfield@sabp.nhs.uk.
Page 76 of 132

Composition of Council of Governors with Constituencies and
Attendance at Council of Governor Meetings in 2010/11
Class Name No of
Council
Meetings
Eligible
Public Constituency – People who live in the communities we serve
No of
Council
Meetings
Attended
Surrey Soma Carpen 4 2
Surrey Stuart Craig 4 4
Surrey Sally-Ann Marks 4 3
Surrey Barbara Nurse 4 3
Surrey Clive Stone 4 3
Surrey Vacant n/a n/a
Hampshire Veronica Kamerling 4 4
Hampshire David Dent 4 3
Rest of England Sedley Wilson 4 4
Public Constituency – People who use services and carers
Learning Disability Pauline Wicks 4 4
Learning Disability Vacant n/a n/a
Other Services Marcus Bonnet (resigned May 2010) 1 0
Other Services Sally Brady 4 4
Other Services Tracey Hayes 4 4
Other Services Don Illman 4 4
Other Services Edward Pottage 4 4
Other Services Stephenne Rhodes 4 1
Carers John Bale 4 2
Carers Maurice Brook 4 4
Carers Leanda Hargreaves (resigned August 2010) 1 1
Carers Paul Thomson (resigned December 2010) 2 0
Staff Constituency
Medical and Dental Laurence Church 4 4
Qualified Nurses Mike Smith 4 2
Care and Social Care
Assistants
Care and Social Care
Assistants
Helen Rujbally (resigned December 2010) 2 1
Doreen Worsfold 4 3
Therapists Christine Openshaw 4 4
Social Workers Alison Arnold (resigned December2010) 3 3
Administrative,
Managerial and Facilities
Richard Wallis 4 4
Page 77 of 132

Class Name No of
Council
Meetings
Eligible
Appointed Governors
No of
Council
Meetings
Attended
NHS Surrey Diane Woods 4 1
NHS Surrey Sheila Rapley (from July 2010) 3 0
NHS Hampshire Tracey Faraday Drake (from July 2010) 3 1
Surrey County Council Dave Sargeant 4 2
Surrey County Council Michael Gosling (from July 2010) 3 2
Hampshire County
Council
Andrew Joy (resigned May 2010)
John Wall (from 24 November 2010)
Borough Councils Andrew Freeman 4 3
General Practitioners Jill Rasmussen 4 0
Voluntary Sector Carole Ann Roycroft, Elmbridge Voluntary Action 4 2
Surrey Police Peter O’Sullivan (resigned April 2010)
Mick Day (from April 2010)
South East Coast
Ambulance Service
Louise Hutchinson 4 2
1
2
n/a
4
0
0
n/a
1
Director attendance at Council of Governor Meetings 2010/11
Name
Non Executive Directors
No of
Council
Meetings
Eligible
No of
Council
Meetings
Attended
Graham Cawsey 1 1
Richard Greenhalgh 1 1
Roshan Bailey 4 4
John Banfield 4 3
Della Fallon 4 3
Peter Harrison 4 3
Barry Rourke 4 2
Richard Vause 4 3
Executive Directors
Fiona Edwards 4 4
Clive Field 3 2
Ann Harrison 1 1
Rachel Hennessy 4 1
Pat Keeling 3 3
Mandy Stevens 4 4
Jo Young 4 3
Page 78 of 132

Membership
Involving people is at the heart of our Vision and Values and we have undertaken active
membership recruitment campaigns since our initial application to become a Foundation
Trust. On 31 March 2011 the membership total stood at 7,734.
Constituency Eligibility Number of Members
Public Constituency – People who live in the communities we serve
Surrey Resident of Surrey 3,213
Hampshire Resident of Hampshire 493
Rest of England Residing in England 429
Learning Disability
Other Services
Carers
Public Constituency – People who use services and carers
Someone who uses learning
disability services
Someone who uses other Trust
services
A carer or family member of
someone who uses services
There are six classes within the staff constituency and staff are aligned to one of these
classes dependent upon their role. All staff employed by the Trust on a fixed-term contract
of more than 12 months or continuously employed by the Trust automatically become
members unless they choose to opt out.
The Council of Governors’ membership group aims to meet quarterly to develop ideas and
effective methods for increasing the Trust’s membership and to monitor progress. The
target public membership has been set by the group as 7,000 and in the coming year plans
will be developed to help us reach this goal. Drop-in sessions were held across the Trust’s
catchment area prior to the 2011 Governor elections to raise awareness of the role of
Governor and to encourage members to stand for election. Our Governors with learning
disabilities continue to be supported by an independent advocacy team to enable them to
engage more fully in their role.
During the year we held our first Members’ Day, combined with the Annual General
Meeting in September, which was well received by those members who attended. Staff
provided information on some of the key change programmes and developments taking
place across the Trust and also demonstrated how we measure quality to ensure continual
service improvement. Presentations were given describing the new hospital liaison service
for people with learning disabilities and the restructuring programme for adult community
mental health services. We plan to build on this event for our second Members Day in
2011.
213
212
360
Page 79 of 132

A newsletter exclusively for members is produced quarterly to keep members informed of
the work of the Trust and to keep them abreast of developments with the Council of
Governors.
Currently members who wish to communicate with either a Trust Governor or Director can
do so by contacting the Associate Director of Governance in the first instance. The Trust is
in the process of updating its Governor and members area of its public website to allow
further interaction between these two stakeholder groups.
Older People Using Services Group with Roshan Bailey (right), special commendation award
Page 80 of 132

Remuneration Report
The Non-Executive Directors remuneration is agreed and approved by the Governors
based on recommendations put before them by the Foundation Trust Board.
The Remuneration and Terms of Service Committee is responsible for making
recommendations to the Board on the Trust’s remuneration policy and, within the terms
of the agreed policy, determining the total individual remuneration package of the
executive directors. During the year the Committee was chaired by the Chairman/Interim
Chairman and the membership comprises all of the Non Executive Directors.
The Chief Executive attends all meetings of the Committee but is not present for
discussions about her own remuneration. The Committee reviews:
■ The remuneration and terms of service of the Chief Executive and those Directors
who report directly to the Chief Executive
■ The performance of those Directors who report directly to the Chief Executive
through reports submitted by the Chief Executive. The Chair will similarly report on
the performance of the Chief Executive
■ Pay data from similar organisations in order to ensure that appropriate
arrangements have been made for the salaries of the Directors
■ Appropriate contractual arrangements for such staff, including the proper
calculation and scrutiny of termination payments, for these and other senior staff
taking account of such national guidance as appropriate
The Committee meets annually as a minimum, but may meet on other occasions as
required. The Chief Executive holds annual appraisal meetings with each Executive Director
to assess progress against objectives.
Senior managers’ contracts which fall within this remit are all substantive and permanent.
The Medical Director is on the national consultant contract and receives an additional
payment for management responsibilities in recognition of the role as Medical Director.
As in the previous year, no general pay uplifts were made to Executive Directors’ pay.
Following recommendations by the Committee, the Board agreed increases in two cases to
reflect changes in responsibilities and significant anomalies against benchmarks. Non
Executive Directors’ remuneration again continued unchanged. No significant awards were
made to past senior managers during 2010/11.
Following the resignation of Graham Cawsey as Chairman, Roshan Bailey acted as Interim
Chairman for the period 14 July 2010 to 15 February 2011. Richard Greenhalgh was
appointed as Chairman from 16 February 2011.
Page 81 of 132

The following interim appointments have been made to the Director of Finance role during
the year to cover the period between the resignation of David Hodson and the
appointment of Clive Field on 1 July 2010:
■ Alison McKay was appointed as Interim Director of Finance for the period 8
February to 27 May 2010
■ Ann Harrison, who is employed by a firm of public sector consultants, acted as
Interim Director of Finance for the period 28 May to 30 June 2010
Signed
Fiona Edwards
Chief Executive
Cash Equivalent Transfer Values
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 disclosure applies.
The CETV figures and the other pension details include the value of any pension benefits in
another scheme or arrangement which the individual has transferred to the NHS pension
scheme. They also include any additional pension benefit accrued to the member as a
result of their purchasing additional years of pension service in the scheme at their own
cost. The 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 benefits transferred from another scheme or arrangement) and
uses common market valuation factors for the start and end of the period.
The Audit Commission, our external auditors, audited the table of salaries and allowances
of senior managers on page 83 and the table of pension benefits of senior managers on
page 84 as part of their audit of the 2010/11 financial statements.
Page 82 of 132

1 Salaries and Allowances
Name Title 2010-11 2009-10
Salary
(bands of
£5,000)
Salary
(bands of
£5,000)
Other
remuneration
(bands of
£5,000)
Benefits in
kind
(rounded to
nearest
£00)
Other
remuneration
(bands of
£5,000)
Benefits in
kind
(rounded to
nearest £00)
£000 £000 £000 £000 £000 £000
Graham Cawsey Chairman 10 - 15 35 - 40
Richard Greenhalgh Chairman 0 - 5 n/a
Roshan Bailey Non Executive Director 25 - 30 0 - 5 10 - 15 0 - 5
John Banfield Non Executive Director 10 - 15 10 - 15
Della Fallon Non Executive Director 10 - 15 0 - 5 10 - 15
Peter Harrison Non Executive Director 10 - 15 10 - 15
Barry Rourke Non Executive Director 10 - 15 10 - 15
Richard Vause Non Executive Director 10 - 15 0 - 5 10 - 15 0 - 5
Fiona Edwards Chief Executive 140 - 145 140 - 145
Andrea Edeleanu Director of Specialist Therapies & Service User Involvement 80 - 85 20 - 25 80 - 85 20 - 25
Clive Field Director of Finance 85 - 90 n/a
Julie Gaze Director of Corporate Affairs 80 - 85 75 - 80
Rachel Hennessy Interim Medical Director 90 - 95 45 - 50 10 - 15
Pat Keeling Director of Strategic Change 85 - 90 85 - 90
Alison McKay Interim Director of Finance 0 - 5 5 - 10
Mandy Stevens Director of Quality & Performance 105 - 110 20 - 25
Jo Young Director of Operations 105 - 110 105 - 110
Roshan Bailey was Interim Chairman from 14 July 2010 to 15 February 2011
Graham Cawsey resigned as Chairman from 13 July 2010
Clive Field started as Director of Finance & Performance on 1 July 2010
Julie Gaze became full time in July 2010. Although Julie did not receive a salary increase, this has meant that the salary band is higher
Richard Greenhalgh was appointed as Chairman from 16 February 2011
Rachel Hennessy started as Interim Medical Director on 24 February 2010 and was appointed as Medical Director from 1 March 2011
Ann Harrison acted as Interim Director of Finance from 12 April to 30 June 2010. Ann is employed by a firm of public sector consultants
Alison McKay acted as Interim Director of Finance from 8 February to 11 April 2010
Mandy Stevens started as Director of Quality and Performance on 11 January 2010
Other remuneration shown for Roshan Bailey, Della Fallon and Richard Vause is for work as Mental Health Act Managers
Page 83 of 132

2 Pensions Disclosure
Name Title Real
increase in
pension at
age 60
(bands of
£2,500)
Lump sum at
aged 60
related to real
increase in
pension
(bands of
£2,500)
Total
accrued
pension at
age 60 at
31 March
2011
(bands of
£5,000)
Lump sum at
age 60
related to
accrued
pension at
31 March
2011 (bands
of £5,000)
Cash
Equivalent
Transfer
Value at 31
March
2011
Cash
Equivalent
Transfer
Value at 31
March
2010
Real
increase in
Cash
Equivalent
Transfer
Value
Employer’s
contribution
to
stakeholder
pension
£000 £000 £000 £000 £000 £000 £000 £000
Fiona Edwards Chief Executive 0 - 2.5 0 - 2.5 25 - 30 75 - 80 426 423 (13) n/a
Andrea Edeleanu
Director of Specialist Therapies &
Service User Involvement 0 - 2.5 2.5 - 5.0 55 - 60 175 - 180 1,269 1,262 (39) n/a
Clive Field Director of Finance (0 - 2.5) (0 - 2.5) 25 - 30 85 - 90 426 468 (35) n/a
Julie Gaze Director of Corporate Affairs 0 - 2.5 0 - 2.5 15 - 20 55 - 60 218 246 (28) n/a
Rachel Hennessy Interim Medical Director 0 - 2.5 2.5 - 5.0 45 - 50 140 - 145 769 791 (44) n/a
Pat Keeling Director of Strategic Change 0 - 2.5 0 - 2.5 30 - 35 95 - 100 644 663 (37) n/a
Alison McKay Interim Director of Finance (0 - 2.5) (0 - 2.5) 10 - 15 40 - 45 191 256 (9) n/a
Mandy Stevens Director of Quality 10 - 12.5 35 - 37.5 20 - 25 70 - 75 274 154 78 n/a
Jo Young Director of Operations 0 - 2.5 0 - 2.5 45 - 50 140 - 145 737 791 (66) n/a
For some Directors there has been a real decrease in pension, lump sum and transfer value (figures shown in brackets) compared to the anticipated 5% increase. This is because there
has been no increase in salary from 2009-10 and, therefore, only a small rise in pension benefits due to an additional year’s membership of the scheme.
Page 84 of 132

Annual Accounts
1 April 2010 – 31 March 2011
Page 85 of 132

Statement of Chief Executive’s
Responsibilities
Statement of the Chief Executive's responsibilities as the Accounting Officer of Surrey
and Borders Partnership NHS Foundation Trust
The National Health Service 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 Officers Memorandum issued by the Independent Regulator
of NHS Foundation Trusts (“Monitor”).
Under the National Health Service Act 2006, Monitor has directed Surrey and Borders
Partnership 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
Surrey and Borders Partnership NHS Foundation Trust and of its income and expenditure,
total recognised gains and losses and cash flows for the financial year.
In preparing the accounts, the Accounting Officer is required to comply with the
requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to:
■ Observe the Accounts Direction issued by Monitor, including the relevant
accounting and disclosure requirements, and apply suitable accounting policies on a
consistent basis
■ Make judgements and estimates on a reasonable basis
■ State whether applicable accounting standards as set out in the NHS Foundation
Trust Annual Reporting Manual have been followed, and disclose and explain any
material departures in the financial statements, and
■ Prepare the financial statements on a going concern basis
The Accounting Officer is responsible for keeping proper accounting records which disclose
with reasonable accuracy at any time the financial position of the NHS Foundation Trust
and to enable him/her to ensure that the accounts comply with requirements outlined in
the above mentioned Act. The Accounting Officer is also responsible for safeguarding the
assets of the NHS Foundation Trust and hence for taking reasonable steps for the
prevention and detection of fraud and other irregularities.
Page 86 of 132

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.
Date: 6 June 2011 Signed: Chief Executive
Page 87 of 132

Annual Governance Report 2011
(Statement on Internal Control)
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.
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 Surrey and Borders Partnership 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 Surrey and Borders Partnership NHS
Foundation Trust for the 12 months ending 31 March 2011 and up to the date of approval
of the annual report and accounts.
Capacity to Handle Risk
The Trust Board has overall responsibility for strategic risks. They define risk tolerance
levels, approval of the process to manage the risks and the assessment and the monitoring
of the efficiency of the risks to ensure the public interest is protected.
The Chief Executive chairs and leads the Executive Board. The Executive Board defines the
risk management strategy, has full control of the risk management system, makes strategic
decisions regarding possible further implementation and development, manages high level
risk and ensures efficient and effective risk mitigation measures and controls.
The Quality Committee is chaired by a Non Executive Director and has delegated authority
from the Board to:
■ Monitor and provide assurance on the quality of the Trust’s services, ensuring
compliance with the regulatory bodies for example Monitor, the Care Quality
Commission (CQC), and the NHS Litigation Authority (NHSLA)
Page 88 of 132

■ Ensure the risks to the delivery of quality services are identified, prioritised and
actions taken to mitigate them within the risk appetite of the Trust
■ Ensure lessons are learned from Serious Untoward Incidents (SUIs)
The Committee reports to the Trust Board and receives reports from the:
■ Mental Health Act Committee
■ Serious Untoward Incident Trends and Lessons Group
■ Trust’s Scrutiny Panel
■ Health and Safety Committee
The Risk and Control Framework
The Trust’s risk management strategy and policy are based on the principle that it is
impossible to eradicate risks, so they must be identified and minimised in a manner that
provides staff with the confidence that the organisation seeks to learn and not to blame
when incidents occur.
The Trust’s risk management strategy is underpinned by policies and processes that allow
all staff proactively to identify and manage risks, incidents, and near misses as they occur.
Training on the concept of risk management and risk reduction is included in the Trust’s
induction for all new staff.
The Trust’s risk management strategy will shortly be updated in line with the Trust’s
incident process that has been reviewed to align it to the Framework for Reporting and
Learning from Serious Incidents. The Trust has also formally adopted the Being Open Policy
as part of its response to a serious incident.
The risk management policy sets out the principles for staff to use in assessing the
likelihood and the impact of an event occurring, identifying the need to develop a
treatment plan for all identified risks, including a timescale for implementing the
treatment plan and the responsible officer. The policy also identifies the line reporting and
accountability arrangements for risk management.
During 2010/11 the Trust further improved its incident management process including
enhanced collaborative working with NHS Surrey (its main commissioner) and the
implementation of an investigations unit. The investigation process is aligned to the
Framework for reporting and learning from serious incidents requiring investigation,
developed by the National Patient Safety Agency. The Trust also has a Board approved
scrutiny panel that oversees the implementation of all agreed actions following a serious
incident investigation.
Page 89 of 132

Board Assurance
The Board Assurance Framework is developed by the Trust’s Executive Board and the
Board of Directors. Its purpose is to ensure that the Board of Directors focuses on the risks
to delivery of the strategic objectives. The strategic objectives drive the Trust Board
Agenda. A Board reporting schedule linked to the assurances and controls was developed
in 2010/11.
The Board Assurance Framework is informed by and linked to the Trust’s High Level Risk
Register and the CQC’s Essential Standards of Quality and Safety. During 2010/11, the Non
Executive Directors worked with the Director of Corporate Affairs and the Associate
Director of Governance to ensure that the Board Assurance Framework provided
meaningful information to the Board and the Audit Committee. This work will continue in
2011/12.
The Trust has service user and carer representatives on all Board sub-committees, with the
exception of the Audit Committee and the Remuneration & Terms of Service Committee.
The review of the relevant area of the Assurance Framework takes into account the views
of all the members of the Committee. In addition the Trust also has a Forum of Carers and
people who Use Services (FoCUS) as one of its governance committees which raises any
issues of concern and has a work programme which holds the Trust to account for any
improvements.
The Policy and Assurance Framework provides assurance to the organisation on its
compliance with obligations under equality, diversity and human rights legislation.
The High Level Risk Register
The High Level Risk Register is informed by individual directorate risk registers. The
Executive Board formally approves and updates the risk register at each meeting. The Trust
Board reviews the risk register on a regular basis, thus demonstrating an embedded
continuous risk review process.
Risk Management Training
Throughout 2010 there was a comprehensive training programme for all appropriately
qualified staff. As a consequence 1140 qualified staff (81 percent who work in the
operations directorate) are now compliant with this training. The compliance period is
three years. There will be a comprehensive rolling three-year process to ensure a supply of
update programmes. Clinical risk training is available at corporate induction for all new
recruits and staff who are already in post who require the programme are also encouraged
to attend the session. The Trust is seeking to design and deliver team-based learning
programmes with a particular focus on learning lessons from critical incidents and
improving confidence and skills in talking with people who use our services who are at risk
of committing suicide.
A bespoke two-day health and safety risk management course is available throughout the
year. 127 managers to date have had health and safety risk management and/or refresher
training.
Page 90 of 132

Periodic Service Reviews
The Trust reviews the quality of its services using a Periodic Service Review (PSR) tool, with
a pass threshold of 85 percent. Services that fail to achieve 85 percent are re-audited
within three months. The tool was adapted in 2010/11 to include the CQC’s Essential
Standards of Quality and Safety. The PSR scores are used as part of the CQC’s assurance
assessment of compliance against its standards.
The PSR annual report to the Quality Committee has reported that a total of 172 services
had a PSR completed in 2011/12 (including registered social care services for the first time
this year). By the end of March 2011, 100 percent of services had scored 85 percent or
more overall and over 85 percent for both the CQC outcomes and the Vision and Values
outcomes. This included improvements in 95 services which successfully implemented
action plans having initially not met the very high standards set by the Trust. The PSR has
demonstrated good assurance of readiness against CQC outcomes – and an improved
position against the Vision and Values outcomes following the reviews.
Details from the PSR process were shared with the Care Quality Commission as part of the
Trust’s Provider Compliance Assessment and feedback received. The PSR process for
2011/12 has begun with minor revisions to the PSR tool incorporating the suggestions
received from the Care Quality Commission.
Information Governance
The Trust’s Caldicott Guardian is the Director of Quality and Performance, a registered
nurse. The Director of Quality and Performance is also the Senior Information Risk Officer
(SIRO) on the Trust Board. The Trust has identified the Directorate Senior Information Risk
Officers (SIROs) and asset owners. Information governance risks are managed by staff
through the use of information governance policies and procedures supported by a
process of in-depth training, training on induction courses and support materials available
on the Trust’s intranet.
The Trust information governance toolkit was submitted on 31 March 2011. The Trust
reported that it achieved level 2 compliance against 18 of the key requirements. The Trust
has an action plan in place to ensure compliance with the remaining four requirements.
Information governance Serious Untoward Incidents (SUIs) are recorded on the Trust’s
High Level Risk Register. No information governance SUIs were recorded during the period
1 April 2010 to 31 March 2011. Information governance risks are monitored through the
Information Governance Steering Group.
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Review of Economy, Efficiency and Effectiveness of the Use of Resources
The Board ensures economy, efficiency and effectiveness through a variety of means
including:
■ A robust pay and non-pay budgetary control system
■ A range of effective and consistently applied financial controls
■ Effective tendering and waiver procedures
■ Robust workforce and establishment control processes
■ Continuous review of service improvements, service delivery and modernisation
■ A robust cost improvement programme ensuring that corporate and operational
units are effectively delivering the savings required and the best allocation of
resources
The Board ensures services are efficient and effective through its annual programme of
Periodic Service Reviews (aligned to the CQC’s essential standards for quality and safety)
and by ensuring our services maintain our registration. The Trust has also improved the
frequency of direct feedback from people using our services, to further improve care
provision, through the introduction of our Patient Experience Trackers. The Trust Board
has also instigated a walk-around programme for Directors to regularly visit and inspect
Trust sites to ensure care standards are being met.
The Trust’s capital disposal programme prioritises sites that can be sold to fund future
service needs. Capital expenditure is prioritised for health and safety, ligature minimisation
and environmental improvement before strategic developments are undertaken.
A proportion of the Trust’s income in 2010/11 was conditional upon achieving quality
improvement and innovation goals. The Trust agreed eight CQUIN (Commission for Quality
and Innovation) indicators with the main NHS commissioners which are monitored at the
NHS contract meetings and internally at the Executive Board.
The Trust is required to register with the Care Quality Commission and its current
registration status is registered without conditions. The Commission has not taken
enforcement action against the Trust during 2010/11.
Regular staff and patient surveys are conducted, ensuring any recommendations are acted
upon and services improved. The Trust has also developed an integrated experience report
as a vehicle for bringing together and sharing direct feedback from people who use our
services and their carers. A Trust scrutiny panel analyses any serious incidents to ensure
lessons can be learnt and appropriate remedial action plans are implemented.
Internal audit ensures constant review of effective control processes are in place to deliver
best value for money. An annual work plan is agreed with the Audit Committee to ensure
areas of concern are addressed.
Page 92 of 132

Annual Quality Report
The Trust has participated in the Monitor Board Leadership for Quality programme to
support its strategic focus on quality improvements. As a result of this work the Board has
set ambitious targets for the next three to five years and has defined its critical
components for quality as Safety, Outcomes and Experience of people who use services
and staff.
These targets have been developed by the Board, building on learning through the year in
talking with people who use services, carers, governors, commissioners, our clinical
leaders, staff and other stakeholders and regulators. They have also been identified
through existing performance monitoring results, including national surveys. Progress
against these targets is reported to the Board throughout the year by the Director of
Quality and Performance (Nurse Director).
The Board also monitors the quality of the Trust’s services against a number of Key
Performance Indicators, including the frequency and trends of Serious Untoward Incidents
and the timely investigation, identification and implementation of lessons to be learnt as a
result.
The Council of Governors also reviews the Key Performance Indicators and is kept
informed by regular service quality performance reports. In addition the Quality and
Accountability Group reviews the Annual Quality Report and is able to make
recommendations on the content.
Review of Effectiveness
As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of
internal control. My review is informed in a number of ways. The Head of Internal Audit
provides me with an opinion on the overall arrangements for gaining assurance through
the Assurance Framework and on the controls reviewed as part of the internal audit work.
Executive Directors within the organisation who have responsibility for the development
and maintenance of the system of internal control provide me with assurance. The
Assurance Framework itself provides me with evidence that the effectiveness of controls
that manage risks to the organisation achieving its principle objectives have been
reviewed.
My review is also informed by detailed reports from both internal and external audit and
feedback from Monitor, the Care Quality Commission and the NHS Litigation Authority.
The Trust has successfully registered all its health and social care services with no
conditions. The two conditions applied to the Trust on initial registration were lifted in
2010. These areas are being closely monitored by the Executive Board. The essential
standards are monitored through the Periodic Service Review process. The Care Quality
Commission has endorsed the use of the Periodic Service Review process as a tool for
gaining assurance.
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During 2010/11 the Trust completed the Delivering Same Sex Accommodation (DSSA) self
assessment by the target date of 31 March 2011. The DSSA declaration has been published
on the Trust’s website together with the action plan to achieve full compliance. Delivery of
the DSSA plan is monitored via the Trust’s Quality Committee, and also through the Trust’s
legally binding contract with NHS Surrey.
In 2010/11 internal audit reported that in its opinion significant assurance has been given
that the Trust has adopted a reasonable procedure of self assessment. In identifying
significant areas of assurance in respect of the design and application of controls further
work was identified in the need to review reliance placed on third party assurances.
Maintenance and review of the effectiveness of the system of internal control has been
provided by the comprehensive mechanisms already referred to in this statement. These
include:
■ Regular reports to the Trust Board from the Trust’s risk register
■ The Annual Quality Report
■ Receipt of minutes/reports from key forums including the Audit Committee and
Trust Governance Committees
■ Monitoring of compliance against the essential standards of quality and safety
■ The ongoing development of the Assurance Framework and associated action plans
including the provision of exception reports to the Trust Board
Conclusion
No significant internal control issues have been identified in the statement of internal
control above.
Signed
Fiona Edwards
Chief Executive
Page 94 of 132

Independent Auditor’s Report
Independent auditor’s report to the Council of Governors of Surrey and Borders
Partnership NHS Foundation Trust
I have audited the financial statements of Surrey and Borders Partnership NHS Foundation
Trust for the year ended 31 March 2011 under the National Health Service Act 2006. The
financial statements comprise the Statement of Comprehensive Income, the Statement of
Financial Position, the Statement of Changes in Taxpayers’ Equity, the Statement of Cash
Flows and the related notes. These financial statements have been prepared under the
accounting policies set out in the Statement of Accounting Policies.
I have also audited the information in the Remuneration Report that is described as having
been audited.
This report is made solely to the Council of Governors of Surrey and Borders Partnership
NHS Foundation Trust in accordance with paragraph 24(5) of Schedule 7 of the National
Health Service Act 2006. My audit work has been undertaken so that I might state to the
Council of Governors those matters I am required to state to it in an auditor’s report and
for no other purpose. To the fullest extent permitted by law, I do not accept or assume
responsibility to anyone other than the Foundation Trust as a body, for my audit work, for
this report or for the opinions I have formed.
Respective Responsibilities of the Chief Executive as Accounting Officer and Auditor
As explained more fully in the Statement of Chief Executive’s Responsibilities, the Chief
Executive is responsible for the preparation of the financial statements and for being
satisfied that they give a true and fair view.
My responsibility is to audit the financial statements in accordance with applicable law, the
Audit Code for NHS Foundation Trusts and International Standards on Auditing (UK and
Ireland). Those standards require me to comply with the Auditing Practice’s Board’s Ethical
Standards for Auditors.
Scope of the Audit of the Financial Statements
An audit involves obtaining evidence about the amounts and disclosures in the financial
statements sufficient to give reasonable assurance that the financial statements are free
from material misstatement, whether caused by fraud or error. This includes an
assessment of:
■ Whether the accounting policies are appropriate to the Trust’s circumstances and
have been consistently applied and adequately disclosed;
■ The reasonableness of significant accounting estimates made by the Trust; and the
overall presentation of the financial statements
Page 95 of 132

I read all the information in the annual report to identify material inconsistencies with
the audited financial statements. If I become aware of any apparent material
misstatements or inconsistencies I consider the implications for my report.
Opinion on Financial Statements
In my opinion the financial statements:
■ Give a true and fair view of the state of affairs of Surrey and Borders Partnership
NHS Foundation Trust’s affairs as at 31 March 2011 and of its income and
expenditure for the year then ended; and
■ Have been properly prepared in accordance with the accounting policies directed by
Monitor as being relevant to NHS Foundation Trusts
Opinion on Other Matters
In my opinion:
■ The part of the Remuneration Report to be audited has been properly prepared in
accordance with the accounting policies directed by Monitor as being relevant to
NHS Foundation Trusts; and
■ The information given in the Annual Report for the financial year for which the
financial statements are prepared is consistent with the financial statements
Matters on Which I Report by Exception
I have nothing to report in respect of the Annual Governance Report (Statement on
Internal Control) on which I report to you if, in my opinion the Annual Governance Report
(Statement on Internal Control) reflects compliance with Monitor’s requirements.
Certificate
I certify that I have completed the audit of the accounts of Surrey and Borders Partnership
NHS Foundation Trust in accordance with the requirements of the National Health Service
Act 2006 and the Audit Code for NHS Foundation Trusts issued by Monitor.
Darren Wells
Officer of the Audit Commission
Audit Commission
2nd Floor, The Agora
Ellen Street, Hove BN3 3LN
6 June 2011
Page 96 of 132

Foreword to the Accounts
Surrey and Borders Partnership NHS Foundation Trust
These accounts for the year ending 31 March 2011 have been prepared by the Surrey and
Borders Partnership NHS Foundation Trust in accordance with paragraphs 24 and 25 of
schedule 7 to the National Health Service Act 2006.
Date: 6 June 2011 Signed: Chief Executive
Page 97 of 132

Statement of Comprehensive Income
for the Year Ended 31 March 2011
2010/11 2009/10
restated
NOTE £000 £000
Operating income 3 170,128 174,618
Operating expenses 4 (165,113) (194,100)
Operating surplus (deficit) (5,015) (16,791)
Finance costs:
Finance income 9 21 13
Finance expense - financial liabilities 10 1 0
Finance expense - unwinding of discount on provisions 11 (274) (225)
Public dividend capital dividends payable 1.14 (5,074) (5,707)
Net finance costs (5,328) (5,919)
Surplus/(Deficit) for the year (313) (25,406)
Other comprehensive income
Impairments 16 (3,459) (10,153)
Revaluations 8,972 10,577
Asset disposals 0 0
Other comprehensive income for the year 5,513 424
Total comprehensive income / (expense) for the year 5,200 24,982
The notes on pages 103 to 128 form part of these accounts.
The 2009/10 transfer to the income and expenditure account of £(25,406)k arose because of
impairments of £(26,776)k and reversal of impairments of £1,267k. Without these impairments the
surplus for 2009/10 would have been £103k.
Page 98 of 132

Statement of Financial Position as at
31 March 2011
31 March 31 March
NOTE 2011 £000 2010 £000
Non-current assets
2011201
Intangible assets 12 3,287
2009
3,314
Property, plant and equipment 14.1 151,859 157,253
Trade and other receivables 20.2 2,858 3,424
Other financial assets 0 0
Other assets 0 0
Total non-current assets 158,004 163,991
Current assets
Inventories 19 82 67
Trade and other receivables 20.1 8,389 8,147
Other financial assets 0 0
Non-current assets for sale 2,739 0
Cash and cash equivalents 22 10,328 4,712
Total current assets 21,538 12,926
Current liabilities
Trade and other payables 23.1 (10,625) (12,324)
Borrowings 24 0 0
Other financial liabilities 0 0
Provisions 28.1 (1,374) (1,871)
Tax payable 23.1 (2,365) (2,470)
Other liabilities 25 (3,099) (1,070)
Total current liabilities (17,463) (17,735)
Total assets less current liabilities 162,079 159,182
Non-current liabilities
Trade and other payables 23.2 0 0
Borrowings 24 0 0
Other financial liabilities 0 0
Provisions 28.2 (7,898) (8,581)
Tax payable 23.2 0 0
Other liabilities 0 0
Total non-current liabilities (7,898) (8,581)
Total assets employed 154,181 150,601
Financed by taxpayers' equity:
Public dividend capital 191,038 192,658
Revaluation reserve 16 20,750 16,974
Donated asset reserve 0 0
Other reserves (13,391) (13,391)
Income and expenditure reserve (44,216) (45,640)
Total taxpayers' equity 154,181 150,601
The financial statements on pages 98 to 128 were approved by the Board and signed on its behalf by:
Signed: Chief Executive Date: 6 June 2011
Page 99 of 132

Statement of Changes in Taxpayers’ Equity – 2010/11
Public Revaluation Donated Other Income and Total
dividend reserve asset reserves expenditure
capital (PDC) reserve reserve
£000 £000 £000 £000 £000 £000
Taxpayers Equity at 1 April 2010
As previously stated 192,658 16,974 252 (13,391) (45,640) 150,601
Changes in taxpayers’ equity for 2010-11
Total Comprehensive Income for the year:
Surplus/(deficit) for the year 0 0 0 0 (313) (313)
Impairments 0 (3,459) 0 0 0 (3,459)
Revaluations 0 8,972 0 0 0 8,972
Asset disposals 0 (1,053) 0 0 1,053 0
Other recognised gains and losses (684) 0 0 684 0
Public Dividend Capital repaid (1,620) 0 0 0 0 (1,620)
Taxpayers Equity at 31 March 2011 191,038 20,750 0 (13,391) (44,216) 154,181
A negative other reserve was created in 2007/08 which related to an error in the 2004/05 revaluation of property, plant and equipment.
Page 100 of 132

Statement of Changes in Taxpayers’ Equity – 2009/10
Public Revaluation Donated Other Income and Total
dividend reserve asset reserves expenditure
capital (PDC) reserve reserve
£000 £000 £000 £000 £000 £000
Taxpayers Equity at 1 April 2009
As previously stated 202,158 19,165 252 (13,391) (23,101) 185,083
Changes in taxpayers’ equity for 2009-10
Total Comprehensive Income for the year:
Surplus/(deficit) for the year 0 0 0 0 (25,406) (25,406)
Impairments 0 (10,153) 0 0 0 (10,153)
Revaluations 0 10,829 (252) 0 0 10,577
Asset disposals 0 (2,867) 0 0 2,867 0
Public Dividend Capital repaid (9,500) 0 0 0 0 (9,500)
Taxpayers Equity at 31 March 2010 192,658 16,974 0 (13,391) (45,640) 150,601
A negative other reserve was created in 2007/08 which related to an error in the 2004/05 revaluation of property, plant and equipment.
The 2009/10 transfer from the income and expenditure account of £(25,406)k arose because of impairments of £(26,776)k and reversal of impairments of
£1,267k. Without these impairments the surplus for 2009/10 would have been £103k.
Page 101 of 132

Statement of Cash Flows for the Year
Ended 31 March 2011
31 March 2011 31 March 2010
NOTE £000 £000
Cash flows from operating activities
Operating surplus/(deficit) from continuing operations 5,015 (19,487)
Operating surplus/(deficit) of discontinued operations 0 0
Operating surplus/(deficit) 5,015 (19,487)
Non-cash income and expense:
Depreciation and amortisation 12 & 14 5,802 5,297
Impairments 14 1,867 26,776
Reversals of impairments 0 (1,267)
Transfer from donated asset reserve 0 (22)
(Increase)/decrease in trade and other receivables 20 324 1,485
(Increase)/decrease in other assets 0 0
(Increase)/decrease in inventories 19 (15) 6
Increase/(decrease) in trade and other payables (1,699) (2,417)
Increase/(decrease) in other liabilities 23 2,029 227
Increase/(decrease) in provisions 28 (1,180) (416)
Tax (paid) / received 23 (105) (155)
Other movements in operating cash flows (3,836) (249)
Net cash generated from / (used in) operations 8,202 9,778
Cash flows from investing activities
Interest received 9 21 13
Purchase of intangible assets 12 (590) (1,195)
Purchase of Property, Plant and Equipment 14 (7,705) (7,028)
Sales of Property, Plant and Equipment 12,146 15,168
Net cash generated from / (used in) investing activities 3,872 6,958
Cash flows from financing activities
Public dividend capital received 0 0
Public dividend capital repaid (1,620) (9,500)
Loans received 0 0
Loans repaid 0 0
Interest paid 0 0
Dividends paid 1.13 (4,838) (5,820)
Net cash generated from / (used in) financing activities (6,458) (15,320)
Net increase/(decrease) in cash and cash equivalents 5,616 1,416
Cash and Cash equivalents at 1 April 22 4,712 3,296
Cash and Cash equivalents at 31 March 10,328 4,712
The deficit at 31 March 2010 arose because of impairments of £(26,776)k and reversal of impairments of
£1,267k. Other movements in operating cash flows for 2010/11 includes £3,325k profit from disposal of
plant, property and equipment. The PDC dividend repaid in 2009/10 totalled £9.5m and represented the
PDC for 17 homes.
Page 102 of 132

Notes to the Accounts
1. Accounting Policies and Other Information
Monitor has directed that the financial statements of NHS foundation trusts shall meet the
accounting requirements of the NHS Foundation Trust Annual Reporting Manual (FT ARM) which
shall be agreed with HM Treasury. Consequently, the following financial statements have been
prepared in accordance with the FT ARM 2010/11 issued by Monitor. The accounting policies
contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury’s
Financial Reporting Manual (FReM) to the extent that they are meaningful and appropriate to NHS
foundation trusts. The accounting policies have been applied consistently in dealing with items
considered material in relation to the accounts.
1.1 Consolidation
Subsidiaries
Subsidiary entities are those over which the Trust has the power to exercise control or a dominant
influence so as to gain economic or other benefits.
For 2010/11, NHS charitable funds considered to be subsidiaries are excluded from consolidation in
accordance with the accounting direction issued by Monitor.
The Trust has no other subsidiaries.
Joint operations
Joint operations are activities which are carried on with one or more other parties but which are not
performed through a separate entity. The Trust includes within its financial statements its share of
the activities, assets and liabilities.
The Trust has no joint operations.
1.2 Income
Income in respect of services provided is recognised when, and to the extent that, performance
occurs and is measured at the fair value of the consideration receivable. The main source of income
for the Trust is contracts with commissioners in respect of health and social care services. Income is
accounted for applying the accruals convention.
Where income is received for a specific activity which is to be delivered in the following financial
year, that income is deferred.
Income from the sale of non-current assets is recognised only when all material conditions of sale
have been met, and is measured as the sums due under the sale contract.
1.3 Expenditure on employee benefits
Short-term employee benefits
Salaries, wages and employment-related payments are recognised in the period in which the service
is received from employees. The cost of annual leave entitlement earned but not taken by employees
at the end of the period is recognised in the financial statements to the extent that employees are
permitted to carry-forward leave into the following period.
Pension costs
NHS Pension Scheme: Past and present employees are covered by the provisions of the NHS Pensions
Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, general
Page 103 of 132

practices and other bodies, allowed under the direction of Secretary of State, in England and Wales.
It is not possible for the NHS foundation trust to identify its share of the underlying scheme liabilities.
Therefore, the scheme is accounted for as a defined contribution scheme.
Employers pension cost contributions are charged to operating expenses as and when they become
due.
Additional pension liabilities arising from early retirements are not funded by the scheme except
where the retirement is due to ill-health. The full amount of the liability for the additional costs is
charged to the operating expenses at the time the trust commits itself to the retirement, regardless
of the method of payment.
1.4 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. Expenditure is accounted for applying the accruals convention.
1.5 Property, plant and equipment
Recognition
Property, Plant and Equipment is capitalised where:
■ It is held for use in delivering services or for administrative purposes;
■ It is probable that future economic benefits will flow to, or service potential be provided to,
the Trust;
■ It is expected to be used for more than one financial year;
■ The cost of the item can be measured reliably;
■ Individually, the items have a cost of at least £5,000; or
■ Form a group of assets which individually have a cost of more than £250, collectively have a
cost of at least £5,000, where the assets are functionally interdependent, they had broadly
simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are
under single managerial control; or
■ Form part of the initial setting-up cost of a new building or refurbishment of a ward or unit,
irrespective of the individual or collective cost.
Where a large asset, for example a building, includes a number of components with significantly
different asset lives e.g. plant and equipment, then these components are treated as separate assets
and depreciated over their own useful economic lives.
Measurement
Valuation
All property, plant and equipment assets are stated at the lower of replacement cost and recoverable
amount. They are measured initially at cost (for leased assets, fair value), representing the costs
directly attributable to acquiring or constructing the asset and bringing it to the location and
condition necessary for it to be capable of operating in the manner intended by management.
All assets are measured subsequently at fair value.
The carrying values of property, plant and equipment are reviewed for impairment in periods if
events or changes in circumstances indicate the carrying value may not be recoverable. The costs
arising from financing the construction of the asset are not capitalised but are charged to the income
and expenditure account in the year to which they relate.
Page 104 of 132

IAS 16 requires that revaluations should be carried out regularly, so that the carrying amount of an
asset does not differ materially from its fair value at the balance sheet date. If an item is revalued,
the entire class of assets to which that asset belongs should be revalued. The Trust will decide
annually how full a revaluation is needed each year but a full, professional revaluation will be carried
out at least every five years.
Valuations are carried out by King Sturge, professionally qualified valuers, in accordance with the
Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation Manual. A full revaluation was
carried out in March 2010 with a comprehensive update completed in March 2011.
The valuations are carried out primarily on the basis of depreciated replacement cost for specialised
operational property and existing use value for non-specialised operational property. The value of
land for existing use purposes is assessed at existing use value. For non-operational properties
including surplus land, the valuations are carried out at open market value.
Additional alternative open market value figures have only been supplied for operational assets
scheduled for imminent closure and subsequent disposal. For assets falling with the Social Care
Change Programme, these are valued using a specific valuation method which has been agreed with
Surrey Primary Care Trust and such valuations are undertaken when there is certainty and agreement
that the asset will transfer.
Assets in the course of construction are valued at cost until they are brought into use when they
enter the standard, annual revaluation exercise.
Operational equipment is valued at net current replacement cost. Equipment surplus to
requirements is valued at net recoverable amount.
Subsequent expenditure
Where subsequent expenditure enhances an asset beyond its original specification, the directly
attributable cost is added to the asset’s carrying value. Where subsequent expenditure is simply
restoring the asset to the specification assumed by its economic useful life then the expenditure is
charged to operating expenses.
Depreciation
Items of Property, Plant and Equipment are depreciated over their remaining useful economic lives in
a manner consistent with the consumption of economic or service delivery benefits. Freehold land is
considered to have an infinite life and is not depreciated. Leaseholds are depreciated over the
primary lease term.
Furniture & fittings 10
Transport equipment 7
Plant & machinery 5
Information Technology 4
Years
Property, Plant and Equipment which has been reclassified as ‘Held for Sale’ ceases to be depreciated
upon the reclassification. Assets in the course of construction are not depreciated until the asset is
brought into use or reverts to the Trust, respectively.
Revaluation gains and losses
Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that,
they reverse a revaluation decrease that has previously been recognised in operating expenses, in
which case they are recognised in operating income.
Page 105 of 132

Revaluation losses are charged to the revaluation reserve to the extent that there is an available
balance for the asset concerned, and thereafter are charged to operating expenses.
Gains and losses recognised in the revaluation reserve are reported in the Statement of
Comprehensive Income as an item of ‘other comprehensive income’.
Impairments
In accordance with the FT ARM, impairments that are due to a loss of economic benefits or service
potential in the asset are charged to operating expenses. A compensating transfer is made from the
revaluation reserve to the income and expenditure reserve of an amount equal to the lower of (i) the
impairment charged to operating expenses; and (ii) the balance in the revaluation reserve
attributable to that asset before the impairment.
Other impairments are treated as revaluation losses. Reversals of ‘other impairments’ are treated as
revaluation gains.
De-recognition
Assets intended for disposal are reclassified as ‘Held for Sale’ once all of the following criteria are
met:
■ The asset is available for immediate sale in its present condition subject only to terms which
are usual and customary for such sales;
■ The sale must be highly probable i.e.:
­ management are committed to a plan to sell the asset;
­ an active programme has begun to find a buyer and complete the sale;
­ the asset is being actively marketed at a reasonable price;
­ the sale is expected to be completed within 12 months of the date of classification as
‘Held for Sale’; and
­ the actions needed to complete the plan indicate it is unlikely that the plan will be
dropped or significant changes made to it.
Following reclassification, the assets are measured at the lower of their existing carrying amount and
their ‘fair value less costs to sell’. Depreciation ceases to be charged and the assets are not revalued,
except where the ‘fair value less costs to sell’ falls below the carrying amount. Assets are derecognised
when all material sale contract conditions have been met.
Property, plant and equipment which is to be scrapped or demolished does not qualify for
recognition as ‘Held for Sale’ and instead is retained as an operational asset and the asset’s economic
life is adjusted. The asset is de-recognised when scrapping or demolition occurs.
1.6 Intangible assets
Recognition
Intangible assets are non-monetary assets without physical substance which are capable of being
sold separately from the rest of the Trust’s business or which arise from contractual or other legal
rights. They are recognised only where it is probable that future economic benefits will flow to, or
service potential be provided to, the Trust and where the cost of the asset can be measured reliably.
Software
Software which is integral to the operation of hardware e.g. an operating system, is capitalised as
part of the relevant item of property, plant and equipment. Software which is not integral to the
operation of hardware e.g. application software, is capitalised as an intangible asset.
Page 106 of 132

Measurement
Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to
create, produce and prepare the asset to the point that it is capable of operating in the manner
intended by management.
Subsequently intangible assets are measured at fair value. Revaluation gains and losses and
impairments are treated in the same manner as for Property, Plant and Equipment.
Intangible assets held for sale are measured at the lower of their carrying amount or ‘fair value less
costs to sell’.
Amortisation
Intangible assets are amortised over their expected useful economic lives in a manner consistent
with the consumption of economic or service delivery benefits.
1.7 Liquid resources
Deposits and other investments that are readily convertible into known amounts of cash at or close
to their carrying amounts are treated as liquid resources in the cash flow statement.
1.8 Inventories
Inventories are valued at the lower of cost and net realisable value.
1.9 Cash, bank and overdrafts
Cash, bank and overdraft balances are recorded at the current values of these balances in the NHS
Foundation Trust’s cash book. These balances exclude monies held in the NHS Foundation Trust’s
bank account belonging to patients (see “third party assets” below). Account balances are only set
off where a formal agreement has been made with the bank to do so. In all other cases overdrafts
are disclosed within creditors. Interest earned on bank accounts and interest charged on overdrafts is
recorded as, respectively, “interest receivable” and “interest payable” in the periods to which they
relate. Bank charges are recorded as operating expenditure in the periods to which they relate.
1.10 Financial assets and financial liabilities
Recognition
Financial assets and financial liabilities which arise from contracts for the purchase or sale of nonfinancial
items (such as goods or services), which are entered into in accordance with the Trust’s
normal purchase, sale or usage requirements, are recognised when, and to the extent which,
performance occurs i.e. when receipt or delivery of the goods or services is made.
Financial assets or financial liabilities in respect of assets acquired or disposed of through finance
leases are recognised and measured in accordance with the accounting policy for leases described
below.
Regular way purchases or sales are recognised and de-recognised, as applicable, using the trade date.
All other financial assets and financial liabilities are recognised when the Trust becomes a party to
the contractual provisions of the instrument.
De-recognition
All financial assets are de-recognised when the rights to receive cashflows from the assets have
expired or the Trust has transferred substantially all of the risks and rewards of ownership.
Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires.
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Classification and measurement
Financial assets are categorised as ‘Fair Value through Income and Expenditure’, ‘Loans and
Receivables’, or ‘Available-for-sale Financial Assets’.
Financial liabilities are classified as ‘Fair Value through Income and Expenditure’ or as ‘Other
Financial Liabilities’.
Financial assets and financial liabilities at ‘Fair Value through Income and Expenditure’
Financial assets and financial liabilities at ‘Fair Value through Income and Expenditure’ are financial
assets or financial liabilities held for trading. A financial asset or financial liability is classified in this
category if acquired principally for the purpose of selling in the short-term. Derivatives are also
categorised as held for trading unless they are designated as hedges. Derivatives which are
embedded in other contracts but which are not ‘closely-related’ to those contracts are separated-out
from those contracts and measured in this category. Assets and liabilities in this category are
classified as current assets and current liabilities.
These financial assets and financial liabilities are recognised initially at fair value, with transaction
costs expensed in the income and expenditure account. Subsequent movements in the fair value are
recognised as gains or losses in the Statement of Comprehensive Income.
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: current investments, cash and cash equivalents, NHS
debtors, accrued income and ‘other debtors’.
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.
Available-for-sale Financial Assets
Available-for-sale Financial Assets are non-derivative financial assets which are either designated in
this category or not classified in any of the other categories. They are included in long-term assets
unless the Trust intends to dispose of them within 12 months of the Statement of Financial Position
date.
Available-for-sale Financial Assets are recognised initially at fair value, including transaction costs,
and measured subsequently at fair value, with gains or losses recognised in reserves and reported in
the Statement of Comprehensive Income as an item of ‘other comprehensive income’. When items
classified as ‘available-for-sale’ are sold or impaired, the accumulated fair value adjustments
recognised are transferred from reserves and recognised in ‘Finance Costs’ in the Statement of
Comprehensive Income.
Other financial liabilities
All other financial liabilities are recognised initially at fair value, net of transaction costs incurred, and
measured subsequently at amortised cost using the effective interest method. The effective interest
rate is the rate that discounts exactly estimated future cash payments through the expected life of
Page 108 of 132

the financial liability or, when appropriate, a shorter period, to the net carrying amount of the
financial liability.
They are included in current liabilities except for amounts payable more than 12 months after the
Statement of Financial Position date, which are classified as long-term liabilities.
Interest on financial liabilities carried at amortised cost is calculated using the effective interest
method and charged to Finance Costs. Interest on financial liabilities taken out to finance property,
plant and equipment or intangible assets is not capitalised as part of the cost of those assets.
Determination of fair value
For financial assets and financial liabilities carried at fair value, the carrying amounts are determined
from discounted cash flow analysis.
Impairment of financial assets
At the Statement of Financial Position date, the Trust assesses whether any financial assets, other
than those held at ‘Fair Value through Income and Expenditure’ are impaired. Financial assets are
impaired and impairment losses are recognised if, and only if, there is objective evidence of
impairment as a result of one or more events which occurred after the initial recognition of the asset
and which has an impact on the estimated future cashflows of the asset.
For financial assets carried at amortised cost, the amount of the impairment loss is measured as the
difference between the asset’s carrying amount and the present value of the revised future cash
flows discounted at the asset’s original effective interest rate. The loss is recognised in the Statement
of Comprehensive Income and the carrying amount of the asset is reduced directly.
1.11 Leases
Finance leases
Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS
Foundation Trust, the asset is recorded as Property, Plant and Equipment and a corresponding
liability is recorded. The value at which both are recognised is the lower of the fair value of the asset
or the present value of the minimum lease payments, discounted using the interest rate implicit in
the lease. The implicit interest rate is that which produces a constant periodic rate of interest on the
outstanding liability.
The asset and liability are recognised at the inception of the lease, and are de-recognised when the
liability is discharged, cancelled or expires. The annual rental is split between the repayment of the
liability and a finance cost. The annual finance cost is calculated by applying the implicit interest rate
to the outstanding liability and is charged to Finance Costs in the Statement of Comprehensive
Income.
Operating leases
Other leases are regarded as operating leases and the rentals are charged to operating expenses on a
straight-line basis over the term of the lease. Operating lease incentives received are added to the
lease rentals and charged to operating expenses over the life of the lease.
Leases of land and buildings
Where a lease is for land and buildings, the land component is separated from the building
component and the classification for each is assessed separately. Leased land is treated as an
operating lease.
1.12 Provisions
The NHS Foundation Trust recognises a provision where it has a legal or constructive obligation of
uncertain timing or amount; for which it is probable that there will be a future outflow of cash or
Page 109 of 132

other resources; and a reliable estimate can be made of the amount. The amount recognised in the
Statement of Financial Position is the basis of the best estimate of the resources required to settle
the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted
cash flows are discounted using HM Treasury’s discount rate of 2.2% in real terms, except for early
retirement provisions and injury benefit provisions which both use the HM Treasury’s pension
discount rate of 2.9% in real terms.
Clinical negligence costs
The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS
Foundation Trust pays an annual contribution to the NHSLA, which, in return, settles all clinical
negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases,
the legal liability remains with the NHS Foundation Trust. The total value of clinical negligence
provisions carried by the NHSLA on behalf of the NHS Foundation Trust is disclosed at note 28.3 but
is not recognised in the NHS Foundation Trust’s accounts.
Non-clinical risk pooling
The NHS foundation trust participates in the Property Expenses Scheme and the Liabilities to Third
Parties Scheme. Both are risk pooling schemes under which the Trust pays an annual contribution to
the NHS Litigation Authority and in return receives assistance with the costs of claims arising. The
annual membership contributions, and any ‘excesses’ payable in respect of particular claims are
charged to operating expenses when the liability arises. The Trust also takes additional commercial
insurance over and above the limits set by these pooled schemes.
Contingencies
Contingent assets (that is, assets arising from past events whose existence will only be confirmed by
one or more future events not wholly within the entity’s control) are not recognised as assets, but
are disclosed in note 29 where an inflow of economic benefits is probable.
Contingent liabilities are not recognised, but are disclosed in note 29, unless the probability of a
transfer of economic benefits is remote. Contingent liabilities are defined as:
■ Possible obligations arising from past events whose existence will be confirmed only by the
occurrence of one or more uncertain future events not wholly within the entity’s control; or
■ Present obligations arising from past events but for which it is not probable that a transfer of
economic benefits will arise or for which the amount of the obligation cannot be measured
with sufficient reliability.
1.14 Public dividend capital
Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets
over liabilities at the time of establishment of the predecessor NHS trust. HM Treasury has
determined that PDC is not a financial instrument within the meaning of IAS 32.
A charge, reflecting the 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, (ii) net cash balances held with the Government Banking Services 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 net
relevant assets as set out in the ‘pre-audit’ version of the annual accounts. The dividend thus
calculated is not revised should any adjustment to net assets occur as a result of the audit of the
annual accounts. Average net assets are calculated as a simple mean of opening and closing relevant
net assets.
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1.15 Value added tax
Most of the activities of the NHS foundation 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.
1.16 Corporation tax
The Trust reviews its activities in the light of current and latest guidance and receives advice to
establish whether it has any corporate tax liabilities. All the activities are outside the scope of
Corporation Tax and the Trust has determined that it has no corporation tax liability.
Foreign exchange
The functional and presentational currencies of the Trust are sterling.
A transaction which is denominated in a foreign currency is translated into the functional currency at
the spot exchange rate on the date of the transaction.
Where the Trust has assets or liabilities denominated in a foreign currency at the Statement of
Financial Position date:
■ Monetary items (other than financial instruments measured at ‘Fair Value through Income and
Expenditure’) are translated at the spot exchange rate on 31 March;
■ Non-monetary assets and liabilities measured at historical cost are translated using the spot
exchange rate at the date of the transaction; and
■ Non-monetary assets and liabilities measured at fair value are translated using the spot
exchange rate at the date the fair value was determined.
Exchange gains or losses on monetary items (arising on settlement of the transaction or on retranslation
at the Statement of Financial Position date) are recognised in income or expense in the
period in which they arise.
Exchange gains or losses on non-monetary assets and liabilities are recognised in the same manner
as other gains and losses on these items.
1.18 Third party assets
Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the
accounts since the NHS foundation trust has no beneficial interest in them. However, they are
disclosed in a separate note to the accounts in accordance with the requirements of HM Treasury’s
FReM.
1.19 Losses and special payments
Losses and Special Payments are items that Parliament would not have contemplated when it agreed
funds for the health service or passed legislation. By their nature they are items that ideally should
not arise. They are therefore subject to special control procedures compared with the generality of
payments. They are divided into different categories, which govern the way each individual case is
handled.
Losses and Special Payments are charged to the relevant functional headings in the Income and
Expenditure Account 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).
However, the losses and special payments note is compiled directly from the losses and
compensations register which reports on an accrual basis with the exception of provisions for future
losses.
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2. Segmental Analysis
The Trust has one segment - healthcare. This is consistent with internal reporting within the Trust.
2010/11 2009/10
£000 £000
Healthcare income 170,128 174,613
Healthcare deficit (313) (25,406)
Healthcare net assets 154,181 150,601
3. Operating Income
Following detailed analysis work to prepare the 2010/11 income breakdown, the figures for 09/10
have been restated. These restatements are of a minimal nature and have been agreed with the
auditors.
3.1 Operating income from patient care activities
2010/11 2009/10
restated
£000 £000
NHS Foundation Trusts 0 161
NHS Trusts 3 198
Primary Care Trusts 120,724 129,239
Local authorities 28,887 28,621
Department of Health - other 0 12
NHS other 72 (20)
Non-NHS: Overseas patients (non-reciprocal) 2 0
Non NHS: Other 939 1,544
150,627 159,755
Local authority revenue from patient care activities includes non-mandatory (social care) income
of £23m (2009/10 £29m).
3.2 Other operating income
2010/11 2009/10
restated
£000 £000
Education and training 2,273 2,172
Non-patient care services to other bodies 7,298 7,864
Profit on disposal of land and buildings 4,787 287
Staff recharges 89 95
Pharmacy sales 47 45
Staff accommodation rentals 67 84
Crèche services 402 380
Catering (1) (11)
Property rentals 150 195
IAPT (increased access to psychology therapies) recharge 352 272
Contribution towards shared management 297 297
Local public sector funding 254 251
Transport 236 120
Bournewood House accommodation recharge 189 0
Farmfield land rental 156 214
Capital charges 159 120
Energy recharges 143 165
Loddon Alliance 96 0
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Continuum support (patient activity recording system) 95 8
Psychology recharges 86 76
Liaison services for older adults 77 42
Emmanus Project (drug and alcohol services) 72 71
LD therapy income 71 36
Other (numerous balances under £70k) 2,106 2,075
Page 113 of 132
19,501 14,858
3.3 Private patient income
The Trust had no private patient income and the private patient cap is 1.5% (2009/10, zero)
4. Operating Expenses
Following detailed analysis work to prepare the 2010/11 expenses breakdown, the figures for
09/10 have been restated. These restatements are of a minimal nature and have been agreed with
the auditors.
2010/11 2009/10
restated
£000 £000
Services from NHS Foundation Trusts 657 335
Services from NHS Trusts 1,601 1,887
Services from other NHS Bodies 703 917
Purchase of healthcare from non NHS bodies 115 49
Employee expenses - Executive directors 1,183 1,110
Employee expenses - Non-executive directors 123 131
Employee expenses - Staff 127,301 133,772
Drug costs 3,243 3,071
Supplies and services - clinical (excluding drug costs) 498 549
Supplies and services - general 2,306 2,739
Establishment 4,568 5,081
Transport 1,288 1,391
Premises 6,835 7,413
Increase / (decrease) in bad debt provision 2,160 2,322
Depreciation on property, plant and equipment 5,185 5,094
Amortisation on intangible assets 617 203
Impairments of property, plant and equipment 1,668 26,776
Reversal of impairments of property, plant and equipment 0 (1,267)
Audit fees :
- statutory audit (including VAT) 76 84
- regulatory reporting 0 0
Other auditor's remuneration : 0 0
- further assurance services (advice & assistance work (external audit)) 21 0
- other services 267 262
Clinical negligence 316 394
Loss on disposal of land and buildings 1,462 150
Impairments of assets held for sale 199 0
Legal fees 405 485
Consultancy costs 311 538
Patient travel 87 106
Redundancy 1,529 93
Early retirements 260 249
Losses, ex gratia & special payments 16 33
Other 113 133
165,113 194,100

5. Operating Leases
5.1 As lessee - payments recognised as an expense
2010/11 2009/10
£000 £000
Minimum lease payments 2,352 2,421
2,352 2,421
5.2 Operating lease expenses
2010/11 2009/10
£000 £000
Medical & surgical equipment 3 8
Office equipment - franking machines 12 13
Photocopiers 95 96
Property 1,695 1,716
Vehicles 512 546
Vending machines 3 5
Water coolers 36 37
All leases for equipment expire within the next three years. Vehicle leases are for between
three and five years and all expire by 2014. Property leases are for between 5 and 25 years
and all expire by 2024.
2,356 2,421
5.3 Total future minimum lease payments
2010/11 2009/10
£000 £000
Payable:
Not later than one year 2,230 2,309
Between one and five years 2,521 3,156
After 5 years 1,514 1,613
Total 6,265 7,078
6. Employee Costs and Numbers
6.1 Employee costs
2010/11 2009/10
Total Permanently Other Total
Employed
£000 £000 £000 £000
Salaries and wages 99,525 99,525 0 101,705
Social security costs 7,760 7,760 0 8,038
Pension costs - defined contribution plans 11,705 11,705 0 12,117
Employers contributions to NHS Pensions
Pension cost - other contributions 0 0 0 0
Termination benefits 0 0 0 0
Agency/contract staff 11,283 0 11,283 13,364
Total 130,273 118,990 11,283 135,224
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6.2 Average number of people employed
2010/11 2009/10
Total Permanently Other Total
Employed
Number Number Number Number
Medical and dental 179 179 0 186
Administration and estates 519 519 0 546
Healthcare assistants & other support staff 649 649 0 489
Nursing, midwifery & health visiting staff 672 672 0 899
Nursing, midwifery & health visiting
learners 18 18 0 2
Scientific, therapeutic and technical staff 297 297 0 334
Social care staff 379 379 0 487
Bank and agency staff 405 0 405 470
Other 0 0 0 0
6.3 Employee benefits
There were no employee benefits
3,118 2,713 405 3,413
7. Retirements Due to Ill-health
During the period April 2010 to March 2011 there was 1 early retirement (2009/10, 8) from the NHS
Trust agreed on the grounds of ill-health. The estimated additional pension liability of this ill-health
retirement will be £119,425 (2009/10, £525,596). This retirement represented 0.36 per 1,000 active
scheme members (2009/10, 2.73 per 1,000). The cost of this ill-health retirement will be borne by the
NHS Business Services Authority - Pensions Division.
8. The Late Payment of Commercial Debts (Interest) Act 1998
During the period April 2010 to March 2011 the interest for late payment of commercial debts was
£1k (2009/10, £0k).
9. Finance Income
2010/11 2009/10
£000 £000
Other - interest received on bank accounts 21 13
10. Finance Expense - Financial Liabilities
21 13
2010/11 2009/10
£000 £000
Interest expense (for late payment of commercial debt) 1 0
1 0
Page 115 of 132

11. Finance Expense
2010/11 2009/10
£000 £000
Unwinding of discount on provisions (274) (225)
12. Intangible Assets
12.1 Intangible assets 2010/11
(274) (225)
Information Intangible Total
Technology assets in
(internally development
generated)
£000 £000 £000
Gross cost at 1 April 2010 1,435 2,198 3,633
Additions purchased 451 139 590
Reclassifications 2,214 (2,214) 0
Disposals 0 0 0
Gross cost at 31 March 2011 4,100 123 4,223
Amortisation at 1 April 2010 319 0 319
Provided during the year 617 0 617
Reclassifications 0 0 0
Disposals 0 0 0
Amortisation at 31 March 2011 936 0 936
Net book value
Purchased 3,164 123 3,287
Donated 0 0 0
Total at 31 March 2011 3,164 123 3,287
Page 116 of 132

12.2 Intangible assets 2009/10
Information Intangible Total
technology
assets in
(internally development
generated)
£000 £000 £000
Gross cost at 1 April 2009 1,215 1,228 2,443
Additions purchased 225 970 1,195
Reclassifications 0 0 0
Disposals (5) 0 (5)
Gross cost at 31 March 2010 1,435 2,198 3,633
Amortisation at 1 April 2009 121 0 121
Provided during the year 203 0 203
Reclassifications 0 0 0
Disposals (5) 0 (5)
Amortisation at 31 March 2010 319 0 319
Net book value
Purchased 1,116 2,198 3,314
Donated 0 0 0
Total at 31 March 2010 1,116 2,198 3,314
13. Revaluation Reserve Balance For Intangible Assets
31 March
2011
31 March
2010
31 March
2009
£000 £000 £000
At 1 April 0 0 0
Revaluation gains / (losses) 0 0 0
At 31 March 0 0 0
Page 117 of 132

14. Property, Plant and Equipment
14.1 Property, plant and equipment 2010/11
Land Buildings Dwellings Assets Plant and Transport Information Furniture Total
excluding under machinery equipment technology & fittings
dwellings
construction
£000 £000 £000 £000 £000 £000 £000 £000 £000
Cost or valuation at 1 April 2010 53,802 95,885 1,379 3,620 983 138 2,384 782 158,973
Additions purchased 0 3,704 17 3,524 26 17 306 112 7,706
Impairments (19) (3,362) (78) 0 0 0 0 0 (3,459)
Reclassifications 0 679 0 (1,075) 0 0 396 0 0
Revaluation surpluses 1,010 3,278 (2) 0 0 0 0 0 4,286
Transfer to assets held for sale (1,165) (1,802) 0 0 0 0 0 0 (2,967)
Disposals (4,140) (4,343) (266) (182) 0 0 0 0 (8,931)
At 31 March 2011 49,488 94,039 1,050 5,887 1,009 155 3,086 894 155,608
Depreciation at 1 April 2010 0 0 0 0 407 101 919 293 1,720
Provided during the year 0 4,381 48 0 182 23 426 125 5,185
Impairments 587 1,077 4 0 0 0 0 0 1,668
Reclassifications 0 0 0 0 0 0 0 0 0
Revaluation surpluses 0 (4,642) (43) 0 0 0 0 0 (4,685)
Transfer to assets held for sale 0 (29) 0 0 0 0 0 0 (29)
Disposals 0 (101) (9) 0 0 0 0 0 (110)
Depreciation at 31 March 2011 587 686 0 0 589 124 1,345 418 3,749
Net book value
Purchased 48,901 93,353 1,050 5,887 420 31 1,741 476 151,859
Donated 0 0 0 0 0 0 0 0 0
Total at 31 March 2011 48,901 93,353 1,050 5,887 420 31 1,741 476 151,859
Asset financing
Owned 48,901 93,353 1,050 5,887 420 31 1,741 476 151,859
Total 31 March 2011 48,901 93,353 1,050 5,887 420 31 1,741 476 151,859
Net book value
Protected assets 24,010 38,985 0 0 0 0 0 0 62,995
Unprotected assets 24,891 54,368 1,050 5,887 420 31 1,741 476 88,864
Total at 31 March 2011 48,901 93,353 1,050 5,887 420 31 1,741 476 151,859
Page 118 of 132

14.2 Property, plant and equipment 2009/10
Land Buildings Dwellings Assets Plant and Transport Information Furniture Total
excluding under machinery equipment technology & fittings
dwellings
construction
£000 £000 £000 £000 £000 £000 £000 £000 £000
Cost or valuation at 1 April 2009 59,772 131,907 3,021 4,757 968 168 2,046 756 203,395
Additions purchased 0 4,798 4 1,676 168 0 296 86 7,028
Impairments (5,082) (10,048) (105) 0 0 0 0 0 (15,235)
Reclassifications 0 1,585 0 (2,813) 0 0 1,228 0 0
Revaluations 3,353 (21,761) (1,347) 0 0 0 0 0 (19,755)
Disposals (4,241) (10,596) (194) 0 (153) (30) (1,186) (60) (16,460)
At 31 March 2010 53,802 95,885 1,379 3,620 983 138 2,384 782 158,973
Depreciation at 1 April 2009 0 4,597 1,003 0 380 104 1,639 259 7,982
Provided during the year 0 4,281 46 0 180 27 466 94 5,094
Impairments 0 21,324 370 0 0 0 0 0 21,694
Reclassifications 0 0 0 0 0 0 0 0 0
Revaluation surpluses 0 (30,202) (1,419) 0 0 0 0 0 (31,621)
Disposals 0 0 0 0 (153) (30) (1,186) (60) (1,429)
Depreciation at 31 March 2010 0 0 0 0 407 101 919 293 1,720
Net book value
Purchased 53,802 95,885 1,379 3,620 576 37 1,465 489 157,253
Donated 0 0 0 0 0 0 0 0 0
Total at 31 March 2010 53,802 95,885 1,379 3,620 576 37 1,465 489 157,253
Asset financing
Owned 53,802 95,885 1,379 3,620 576 37 1,465 489 157,253
Total 31 March 2010 53,802 95,885 1,379 3,620 576 37 1,465 489 157,253
Net book value
Protected assets 27,245 57,061 0 0 0 0 0 0 84,306
Unprotected assets 26,557 38,824 1,379 3,620 576 37 1,465 489 72,947
Total at 31 March 2010 53,802 95,885 1,379 3,620 576 37 1,465 489 157,253
Page 119 of 132

14.3 Net book value of finance leases
The Trust has a finance lease for part of the land at Farnham Road Hospital. This lease specifies that
the land should be used for health care and is for 999 years. It commenced in the 1920s and,
therefore, has over 900 years to run. There is no rental paid, and, therefore, no finance lease rental
obligation. The total value of the land is included in property, plant and equipment.
15. Impairments
31 March
2011
31 March
2010
£000 £000
Loss or damage from normal operations 0 124
Changes in market price 5,127 36,805
16. Revaluation Reserve Balance for Property, Plant and Equipment
31 March
5,127 36,929
31 March
2010
2011
£000 £000
Balance at 1 April 16,974 19,165
Impairments (3,459) (10,153)
Revaluations 8,972 10,829
Asset disposals (1,053) (2,867)
Other recognised gains and losses (684) 0
At 31 March 20,750 16,974
17. Capital Commitments
Contracted capital commitments at 31 March not otherwise included in these financial statements:
31 March
2011
31 March
2010
£000 £000
Property, plant and equipment 1,170 1,648
Intangible assets 12 587
18. Investments
The Trust has no investments
1,182 2,235
Page 120 of 132

19. Inventories
31 March
2011
31 March
2010
£000 £000
Drugs 69 55
Consumables 13 12
82 67
Of which held at net realisable value: 0 0
20. Trade and Other Receivables
20.1 Trade and other receivables - current
31 March
2011
31 March
2010
£000 £000
NHS receivables 3,211 3,697
Other receivables with related parties 6,998 2,005
Provision for impaired receivables (3,995) (2,546)
Prepayments 939 1,077
Prepayments - capital contributions 0 0
Accrued income 458 883
PDC receivable 0 113
Other receivables 778 2,918
8,389 8,147
20.2 Trade and other receivables – non-current
31 March
2011
31 March
2010
£000 £000
NHS receivables 2,858 3,424
Other receivables with related parties 0 0
Provision for impaired receivables 0 0
Prepayments 0 0
Prepayments - capital contributions 0 0
Accrued income 0 0
Other receivables 0 0
2,858 3,424
The great majority of trade is with primary care trusts, as commissioners for NHS patient care
services. As primary care trusts are funded by government to buy NHS patient care services, no credit
scoring of them is considered necessary.
20.3 Receivables past their due date but not impaired
31 March
2011
31 March
2010
£000 £000
By up to three months 1,508 1,274
By three to six months 898 1,328
By more than six months 4,436 3,827
6,842 6,429
Page 121 of 132

20.4 Provision for impairment of receivables
31 March 31 March
2011
2010
£000 £000
Balance at 1 April 2,546 847
Increase in provision 2,568 2,416
Amounts utilised (711) (623)
Unused amounts reversed (408) (94)
Balance at 31 March 3,995 2,546
These are provisions for bad debts assessed on an annual basis using an estimate of probability of
collection.
21. Assets Held For Sale - Property, Plant & Equipment
31 March 31 March
2011
2010
£000 £000
Balance at 1 April 0 0
Assets classified as available for sale in the year 2,938 0
Impairment of assets held for sale (199) 0
Balance at 31 March 2,739 0
Assets held for sale represents 7 properties, of which 5 are learning disability social care homes.
These properties are currently under offer with sales expected within 6 months.
22. Cash and Cash Equivalents
31 March 31 March
2011
2010
£000 £000
Balance at 1 April 4,712 3,296
Net change in year 5,616 1,416
Balance at 31 March 10,328 4,712
Made up of :
Cash at commercial banks and in hand 55 64
Cash with the Government Banking Service 10,273 4,648
Cash and cash equivalents as in statement of financial 10,328 4,712
Position
Cash & cash equivalents as in statement of cash flows 10,328 4,712
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23. Trade and Other Payables
23.1 Trade and other payables – current
31 March 2011 31 March 2010
£000 £000
NHS payables 2,249 3,584
Amounts due to other related parties 889 869
Trade payables – capital 729 734
Other trade payables 927 1,703
Taxes payable 2,365 2,470
Other payables 1,440 1,522
Accruals 4,268 3,912
PDC payable 123 0
12,990 14,794
Other payables includes £1,395,923 outstanding pensions contributions at 31 March 2011
(£1,447,112 at 31 March 2010).
23.2 Trade and other payables - non current
31 March 2011 31 March 2010
£000 £000
NHS payables 0 0
Amounts due to other related parties 0 0
Trade payables - capital 0 0
Other trade payables 0 0
Taxes payable 0 0
Other payables 0 0
Accruals 0 0
0 0
Standard trading terms are 30 days from date of invoice, with the exception of tax and social security
which are paid within 18 days of the month end.
24. Borrowings
The Trust had no borrowings during the year
25. Other Current Liabilities
31 March 2011 31 March 2010
£000 £000
Deferred income 3,099 1,070
Total 3,099 1,070
Deferred income includes £2.22m funding for accommodation to be refurbished in 2011/12 at 5 & 6
Ethel Bailey Close and Downham Cottage for former occupants of the LD campus.
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26. Prudential Borrowing Limit
The NHS Foundation Trust is required to comply and remain within a prudential borrowing limit. This is
made up of two elements:
- the maximum cumulative amount of long-term borrowing. This is set by reference to the four ratio
tests set out in the Prudential Borrowing Code for NHS Foundation Trusts. The financial risk rating
set under Monitor’s Compliance Framework determines one of the ratios and therefore can impact
on the long term borrowing limit; and
- the amount of any working capital facility approved by Monitor.
Further information on the Prudential Borrowing Code for NHS Foundation Trusts and Compliance
Framework can be found on the Monitor's website.
31 March 2011 31 March 2010
£000 £000
Total long term borrowing limit set by Monitor 29,300 30,800
Working capital facility agreed by Monitor 12,000 12,000
Total Prudential Borrowing Limit 41,300 42,800
The Trust has a prudential borrowing limit of £41,300k in 2010/11 (£42,800k in 2009/10). The Trust
did not borrow against this limit during the year and had no outstanding borrowing at 31 March
2011 (31 March 2010, nil).
The Trust has £12,000k of approved working capital in 2010/11 (£12,000k in 2009/10). The Trust
had not drawn down any of its working capital facility at 31 March 2011 (31 March 2010, nil).
27. Finance Lease Obligations
The Trust has no finance lease obligations.
28. Provisions
28.1 Provisions - current
31 March 2011 31 March 2010
£000 £000
Pensions relating to other staff 952 956
Legal claims 51 244
Agenda for change 239 405
Other 132 266
Total 1,374 1,871
28.2 Provisions – non-current
31 March 2011 31 March 2010
£000 £000
Pensions relating to other staff 7,834 8,538
Legal claims 64 43
Total 7,898 8,581
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28.3 Provisions - analysis of total
Pensions Legal Agenda Other Total
relating to claims for
other staff
Change
£000 £000 £000 £000 £000
At 1 April 2010 9,494 287 405 266 10,452
Arising during the year 0 76 137 12 225
Used during the year (982) (228) (49) (146) (1,405)
Reversed unused 0 (20) (254) 0 (274)
Unwinding of discount 274 0 0 0 274
At 31 March 2011 8,786 115 239 132 9,272
Expected timing of cash flows:
In the remainder of the spending 952 51 239 132 1,374
review period to 31 March 2011
Between 1 April 2011 and 31 3,808 64 0 0 3,872
March 2016
Between 1 April 2016 and 31 3,808 0 0 0 3,808
March 2021
Thereafter 218 0 0 0 218
Pensions relating to other staff are based on actuarial assessment of life expectancy by the NHS
Pensions Agency. This will be paid over the lifetime of these staff.
In 2010/11 the discount rate recommended by HM Treasury was changed from 2.2% to 2.9%.
Agenda for Change provisions are expected to be paid within the 2010/11 financial year.
£1,626,000 is included in the provisions of the NHS Litigation Authority at 31 March 2011 (31
March 2010, £1,273,000) in respect of clinical negligence liabilities of the Trust.
29. Contingencies
There were no contingencies.
30. Private Finance Transactions
The Trust has no PFI schemes either on or off balance sheet.
31. Financial Instruments
31.1 Financial assets
Loans and Assets Total
receivables
at fair
value
through
the I & E
£000 £000 £000
Trade and other receivables 10,114 0 10,114
Cash and cash equivalents 10,328 0 10,328
Total at 31 March 2011 20,442 0 20,442
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31.2 Financial liabilities
Other financial Liabilities at fair Total
liabilities value through
the I & E
£000 £000 £000
Trade and other payables 9,210 0 9,210
Provisions under contract 9,272 0 9,272
Total at 31 March 2011 18,482 0 18,482
31.3 Fair values of financial assets
Book value
Fair value
£000 £000
Non current trade and other receivables 2,858 2,858
Other 0 0
Total 2,858 2,858
31.4 Fair values of financial liabilities
Book value
Fair value
£000 £000
Non current trade and other payables 0 0
Provisions under contract 9,272 9,272
Other 0 0
Total 9,272 9,272
At 31 March 2011 there were no significant differences between fair value and carrying value of
any of the Trust's financial instruments.
31.5 Financial risk management
Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments
have had during the period in creating or changing the risks a body faces in undertaking its
activities. Because of the continuing service provider relationship that the NHS Trust has with
primary care trusts and the way those primary care trusts are financed, the NHS 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's ability to borrow is governed by the Prudential Borrowing Limit which allows the
Trust to borrow or invest surplus funds. Financial assets and liabilities are generated by day-today
operational activities rather than being held to change the risks facing the NHS 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.
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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.
Interest rate risk
The Trust has no external borrowing and so is not exposed to any significant interest rate risk. However,
the Trust could borrow from government for capital expenditure, subject to affordability as confirmed
by the strategic health authority.
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 2010 are in receivables
from customers, as disclosed in the Trade and other receivables note.
Liquidity risk
The Trust’s operating costs are incurred under contracts with primary care trusts, which are financed
from resources voted annually by Parliament. The Trust funds its capital expenditure from funds
obtained within its prudential borrowing limit. The Trust is not, therefore, exposed to significant
liquidity risks.
32. Events After the Reporting Period
The Trust is currently consulting on a proposed restructure of corporate services. This consultation ends
on 2 April 2011 and a summary of the responses will be discussed at the Joint Consultative Committee in
April. If approved, the proposals may lead to some redundancies, however, these cannot be quantified
at this point in time.
33. Related Party Transactions
Details of key management compensation payments can be found in the Remuneration Report on page
81.
During 2010/11 payments of £10,969 (2009/10, £10,108) have been made to Basingstoke and Deane
District Council, a party related to Fiona Edwards, Chief Executive. In addition, there is a creditor of
£7,893 (2009/10, £8,144) relating to Basingstoke and Deane District Council.
During 2010/11 payments of £35,371 (2009/10, £306) have been made to Pearson Education Ltd, a
party related to Della Fallon. In addition, there is a creditor of £3,184 (2009/10, £0) relating to Pearson
Education Ltd.
During 2010/11 payments of £3,695 (2009/10, £0) have been made to Kings College Hospital NHS
Foundation Trust, a party related to Clive Field, Director of Finance.
Payments to Receipts from Amounts Amounts
related party related party owed to due from
related party related party
£ £ £ £
Fiona Edwards 10,969 0 7,893 0
Della Fallon 35,371 0 3,184 0
Clive Field 3,695 0 0 0
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The Department of Health is regarded as a related party. During 2010/11 Surrey and Borders
Partnership NHS Foundation Trust has had a significant number of material transactions with the
Department, and with other entities for which the Department is regarded as the parent Department.
These entities are listed below:
2010/11 2009/10
£000 £000
Ashford and St Peter's Hospitals NHS Trust 7,597 5,608
Croydon PCT 1,686 4,689
Epsom & St Helier University Hospitals Trust 5,602 4,034
Frimley Park Hospital NHS Foundation Trust 3,973 2,339
Hampshire PCT 11,717 11,312
Royal Surrey County Hospital NHS Foundation Trust 1,616 972
South Downs Health NHS Trust 1,034 851
South East Coast SHA 7,730 7,896
Surrey PCT 176,054 181,575
Surrey & Sussex Healthcare NHS Trust 2,992 2,642
Surrey Health Informatics Service 2,778 2,778
Wandsworth PCT 1,211 1,617
Department of Health 4,307 18
NHS Business Services Authority (formerly Prescription Pricing Authority) 7,666 6,239
NHS Confederation 54 40
NHS Connecting for Health 11 0
NHS Employers 3 3
NHS Litigation Authority 1,195 1,095
NHS Pensions Agency 4,819 3,734
NHS Professionals 29,715 21,394
NHS Supply Chain 3,769 2,903
Other NHS organisations (under £1,000,000) 3,702 2,767
In addition, the Trust has had a number of material transactions with other Government Departments
and other central and local Government bodies. These entities are listed below:
Croydon London Borough Council 6,458 5,330
Hampshire County Council 3,190 3,007
Surrey County Council 23,466 18,630
Sutton London Borough Council 1,281 1,980
34. Third Party Assets
The Trust held £4,720,000 cash and cash equivalents at 31 March 2011 (£5,327,000 at 31 March 2010)
which relates to monies held by the NHS Trust on behalf of patients. This has been excluded from the
cash and cash equivalents figure reported in the accounts.
35. Losses and Special Payments
During 2010/11, there were 128 (2009/10, 124) cases of losses and special payments totalling
£724,000(2009/10, £649,000) paid during the period. Of these, 98 cases totalling £711,000 related to
bad debts. There were no compensation payments received.
36. Charitable Funds
For 2010/11, NHS charitable funds considered to be subsidiaries are excluded from consolidation in
accordance with the accounting direction issued by Monitor. However, the value of these funds is
£369,000 (2009/10, £378,000).
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Surrey and Borders Partnership NHS Foundation Trust
18 Mole Business Park
Leatherhead
Surrey KT22 7AD
Tel: 01883 383838
Email: communications@sabp.nhs.uk
www.sabp.nhs.uk
If you require this document in another format please call the
Communications Department on 01372 205813
Publication date: June 2011