BHRUT annual report 2009 - Barking Havering and Redbridge ...

Annual Report & Accounts 2009-2010
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However, even though the financial position remains
extremely challenging, and given the actions of the
Trust and NHS London, the auditor does not believe it
would be appropriate to issue a public interest report
at this time, but will keep the position under review.
Targets: The emergency care target (98%) was not
achieved for 2009/10. The performance for quarter 4
was 96.73% with a year end performance at 97.31%
(King George was 98.95% and Queen’s 96.02%).
The Trust had 0 patients who were detained in the A
& E Department in excess of 12 hours during 2009/10.
18 week waits: The Trust met the Trust level targets
for both Admitted and Non-Admitted Pathways and
achieved the Non-Admitted target in all specialties.
The Trust met the specialty specific target for
Admitted Pathways in all specialties except ENT.
S4BH/Care Quality Commission Registration: The
Trust has self assessed against the Standards for Better
Health core standards element of the Annual Health
Check, throughout 2009/10. 22 of the 24 standards
were deemed to be compliant, with C5c – Clinician
Training, remaining ‘not met’ and C11c –staff
appraisal has “insufficient evidence”, until Q3 when a
compliance was deemed to have been achieved. This
self assessment process continued in tandem with the
developing guidance for registration requirement.
In January 2010, the Trust completed the self
assessment for registration and following careful
review declared non-compliance in 5 areas, including
staffing of medical wards in Queen’s and King George
Hospitals, Midwifery staffing shortfall in Queen’s
maternity unit and non-compliant areas for the
Sydenham Centre in relation to training and estates
prior to the move to a new building.
Following 3 unannounced visits based on compliance
with the hygiene code, the Care Quality Commission
(CQC) identified further areas of concern and in
conjunction with additional external evidence set
conditions on the Trust’s registration in the following 8
areas:
• Resuscitation training
• Appraisal
• Discharge Planning
• Pressure Damage
• Staffing Levels
• Child Protection Training
• Nurse Mandatory Training
• Use of Contingency Areas.
The CQC stipulated time frames for compliance and
the Trust has developed an action plan and monitoring
structures to ensure compliance in all areas. An
application was made in April to remove the ‘Use of
Contingency Areas’ condition.
In light of the CQC conditions the Trust reviewed the
S4BH compliance and declared insufficient evidence in
C5c and C11c, training and appraisal.
Case of Indentified Fraud: In March 2009, the Local
Security Management Services (LSMS) received
information from the Local Counter Fraud Specialist
(LCFS) that a Security Supervisor at King George
Hospital had been removing money from the King
George Hospital car park machines. This issue was
raised by members of the security staff team. During
the investigation by LCFS it was established that the
Security Supervisor had appropriated a set of keys for
the payment machines outside of Trust policy and had
been accessing them outside the official emptying
hours for a number of years, often taking up to
£1000.00 per week. Following police involvement the
Security Advisor was arrested on 7th July 2009 and
charged with theft. On 8th January 2010, the Security
Supervisor was given a 26 weeks sentence on a 2 year
suspension and an 18 month drug and alcohol
assessment order. The Judge directed that the monies
recovered from the police search be returned to the
Trust. All procedures were reviewed and new ones
implemented to prevent a re-occurrence.
This concludes the Statement of Internal Control for
Barking, Havering and Redbridge University Hospitals
Trust.
Signed
John Goulston
Chief Executive
Date: 9 June 2010
Annual Accounts