Velindre NHS Trust

Annual Report

2014/15

Delivering quality, care & excellence

Darparu ansawdd, gofal a rhagoriaeth

Delivering quality, care & excellence

Darparu ansawdd, gofal a rhagoriaeth

Contents

Introduction 3Who we are 5Welsh Blood Service 6Velindre Cancer Centre 14Annual Governance Statement 2014-2015 23Annual Quality Statement 53Statutory Compliance 83Operating and Financial Review 111

Electronic and Welsh versions of this document can be accessed via the Trust website at;

www.velindre-tr.wales.nhs.uk

If you require additional copies of this document or an alternative format, such as audio, large print or Braille, please contact;

James HodgsonHead of Communication

Velindre NHS Trust Headquarters2 Charnwood Court

Parc NantgarwCardiff

CF15 7QZ029 2019 6161 ext. 6586

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Introduction

This annual report for 2014/15 outlines some of Velindre NHS Trust’s achievements and exciting developments which enhance the services we provide to our patients and donors. During the year we have continued to demonstrate our commitment to providing excellent services, while driving forward key developments to ensure the people of South East Wales and beyond benefit from care of the highest possible quality.

As you read through this report we hope you will gain an understanding of the work the Trust has been doing and see that our main priority is to provide our patients, donors and the public with the best possible services, treatment and care. We have continued to invest in state of the art technology and in providing our patients and donors with the very best care and services in partnership with Welsh Government.

Clearly 2014/15 has been a productive year for the Trust, but alongside our day-to-day activity, we are committed to developing and future-proofing our services. We have been focused on introducing an All Wales Blood Service in 2016, as directed by Welsh Government, to ensure that the long term security of collection, processing, testing, and supply of blood in Wales is maintained.

In the last year we have also been developing proposals to enhance cancer services in South-East Wales, including building a new world-class cancer centre. Welsh Government has supported our Strategic Outline Plan and we will continue to work with our commissioners to develop the next phase of a business case to be submitted for approval in late 2015.

We are immensely proud of our dedicated staff, who strive for excellence and work hard to improve on every aspect of what we do by learning, understanding, changing and delivering the care and services we provide.

Financially, the Trust remains in a sound position. We achieved a strong financial position with a revenue surplus at the end of 2014/15., and continue to deliver top quality care in financially difficult times for public services, ensuring the public gets excellent value for money.

We are delighted to be able to report that 2014/15 has been another successful year for our charity ‘Velindre NHS Trust Charitable Funds’. The generous donations from our supporters, both individual and corporate, enabled us to raise more than £2.9million. This has allowed the Trust to further invest in the patient and donor care environment and our research capability and capacity.

Our focus on excellence has seen us continue to improve the high quality services we provide to our patients and donors. The details contained in this report show that we are maintaining and improving our performance in a range of vital areas.

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We believe the examples illustrated throughout this report will assure you that our staff, members, volunteers, fundraisers and partners are firmly committed to delivering our goal of ‘Quality, Care and Excellence’.

Professor Rosemary Kennedy Mr Steve Ham Chair Interim Chief Executive

Who we are

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Established in 1994, Velindre NHS Trust (the Trust) provides a range of specialist services at local, regional and all Wales levels. Delivering quality, care and excellence to our patients and donors is at the heart of our organisation.

The services we provide: The Welsh Blood Service

The Welsh Blood Service plays a fundamental role in the delivery of healthcare in Wales. It works to ensure that the donor’s gift of blood is transformed into safe and effective blood components which allow NHS Wales to improve the quality of life and save the lives of many thousands of people in Wales every year.

Velindre Cancer Centre

Velindre Cancer Centre in Whitchurch, Cardiff, provides specialist cancer services to people living in South East Wales and is one of the 10 largest cancer centres in the UK. The Cancer Centre is a specialist treatment, teaching and research and development centre for non-surgical oncology, treating patients with chemotherapy, radiotherapy and related treatments, and caring for patients with specialist palliative care needs.

Hosted Organisations The Trust hosts a number of organisations on behalf of Welsh Government and NHS Wales:

NHS Wales Informatics Service (NWIS) NHS Wales Shared Services Partnership (NWSSP) National Institute for Social Care and Health Research

Clinical Research Centre (NISCHR CRC) National Collaborating Centre for Cancer (NCC-C)

For more information on these hosted organisations, please see our Annual Governance Statement on page 23 of this report,

Welsh Blood Service –

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Key Achievements in delivering excellent services in 2014/15

Working towards an All Wales Blood Service

Throughout 2014/15 substantial progress has been made towards the Welsh Blood Service delivering an all-Wales service.

We have continued to work closely with a range of organisations in defining the future service model, which has now been approved by Welsh Government and other NHS Wales partner organisations.

In 2012, the Welsh Government announced that the Welsh Blood Service would take over the blood collection and supply of blood in North Wales, a role that is currently undertaken by England- based NHS Blood and Transplant (NHSBT).

The Welsh Blood Service is committed to making the ministerial announcement a reality by extending the current services we provide to South, West and Mid Wales hospitals into North Wales.

Our priority has now shifted to the implementation of the new service, which is planned to go live in May 2016. We are looking forward to extending our services to North Wales and to working closely with the North Wales donors, NHS staff and the staff who will transfer to us from NHSBT.

Our website is regularly updated with our progress www.welsh-blood.org.uk

Blood Establishment Computer System (BECS)

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In 2014/15 the Welsh Blood Service worked towards introducing a new computer system which is robust and fit for the future.

The new system is used worldwide by many blood transfusion services and enables the service to configure the system to suit the specific needs of the Blood Transfusion Service in Wales.

The introduction of the new computer system will ensure we continue to serve our current and future generations of donors, as well as the hospitals we supply blood to. The new system will be easier, better and safer.

On the frontline - the service will lead the way by introducing easy-to-use touch screens for donors to complete their health questionnaire.

An extra measure of safety – the new system will automatically alert staff to risk factors identified on the donor health questionnaire. The system is being continually improved, so we can expect more benefits in years to come.

New Blood Testing EquipmentSignificant strides have been made to ensure that quality and safety remain at the heart of everything we do and a sustained commitment to meet increasingly stringent regulatory standards for the benefit of patients in Wales.

The Welsh Blood Service successfully secured £1,050,201 funding from Welsh Government to invest in a replacement programme for new state of the art blood testing equipment.These are essential pieces of equipment designed to perform numerous tests to screen blood for diseases such as HIV, Hepatitis B & C, the human T-lymphotropic virus or human T-cell lymphotropic virus and Syphilis. Such tests help to ensure that patients have timely access to a

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safe and sufficient supply of blood, blood products and blood components. The machines also provide the Welsh Blood Service with contingencies in case of failure in any one single piece of equipment. Between installation and the ‘go live’ date, staff were trained to use the equipment and an extensive validation was performed to ensure the complete system was fit for purpose.

New Digital Telephone SystemThe Welsh Blood Service has introduced a new digital telephone system that will improve our ability to answer donor calls.

Blood donors can make appointments using the new bilingual system, which also directs them to the most appropriate department in a clear and efficient manner.

The new system includes Welsh Language options for donors and will help future proof arrangements in readiness for the establishment of an All Wales Blood Service in 2016.

Donor AwardsThe Welsh Blood Service has continued its donor awards evening programme, celebrating the achievement of blood, platelet and bone marrow donors who have reached milestone donations to help reinforce our critical dependence on their altruistic donations and demonstrate the difference their life saving donations have made by bringing donors and patients together.

Bone Marrow Donations in Wales reach 900 Milestone

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In July 2014 the Welsh Blood Service reached a significant milestone of 900 blood stem cell donations since 1989, supporting patients in 30 different countries around the world.

Since the first donation in 1989 the number of donations has increased year on year; in 2014-15 we managed 60successful donations – a very good number for the size of the Welsh Bone Marrow Donor Registry (WBMDR). Originally donations were only supplied for patients within the UK but in 1996 the Welsh Bone Marrow Donor Registry (WBMDR) donors were made available for patients throughout the world, providing our first bone marrow donation for an overseas patient in 1997.

Bone marrow transplants are used to treat patients with blood cancer and other blood disorders.Cath O’Brien, Director of the Welsh Blood Service, said: “Joining the bone marrow register is easy. After receiving your consent, they take a small blood sample from you when you give blood. The sample is then tissue typed and added to the register.

“Reaching this milestone would not have been possible without our blood donors joining the registry and when selected as a match, agreeing to give a potentially lifesaving stem cell donation. A huge thank you to the 900 incredible donors who have helped patients in desperate need and given them hope of a second chance.”

Doctor goes the extra mileSarah Herbert donated her stem cells to a patient in desperate need of a transplant. Working as a doctor in a busy A&E unit allows Sarah to save lives and help people get well on a daily basis. When Sarah received the call from our team at the WBS with the news ‘You could be a potential match’ she was overwhelmend and felt privileged to give someone the opportnity of a second chance. If you would like to see Sarah sharing her story and experience of being selected, please visit the Welsh Blood Service You Tube channel: https://www.youtube.com/watch?v=0TBSRGGtCdQ

Currently the WBMDR has over 60,795 potential donors active on the Welsh register.

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1500th Platelet DonationCongratulations to dedicated donor Kevin Barnes from Hay-on-Wye on reaching his 1,500 platelet donation - an amazing achievement!

Similar to a whole blood donation, a platelet donation consists of four steps: registration, health history, donation and refreshments. From registration to refreshments, the process lasts 90 minutes. Due to the efficiency of donating solely platelets, one single donor can produce sufficient platelets to provide up to three bags of platelet products.

If you would like to take the first step to becoming a platelet donor, please ask a member of staff at your next blood donating clinic or visit www.welshbloog.org.uk

Cable News Network (CNN) film at the Welsh Blood Servicemarks the centenury of the First World War

The Welsh Blood Service helped mark the centenary of the First World War when it welcomed the CNN film crew to the WBS in August 2014.

One of the many stories American news channel CNN covered in recognition of the 100th anniversary is how war helped establish the importance of blood transfusion and how it saved more lives as techniques improved during the

conflict.

The final part of the film included a piece about the Welsh Blood Service, which highlighted how the process has evolved since its inception and is still a crucial part of medical treatment today.

The film emphasised the importance of blood donation in modern medicine and the services provided by the Welsh Blood Service for the benefit of patients in Wales.

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Young DonorsThe Welsh Blood Service was proud to hold its very first dedicated blood donation session at Ysgol Stanwell School in March 2015. An amazing 110 students and staff came forward! There was a fantastic atmosphere in the school and it was great to welcome so many first time donors and staff, all rolling up their sleeves to make a difference. The Welsh Blood Service

Education Programme continues to grow from strength to strength, with the aim in the future to encourage other High Schools to host blood donation clinics which are dedicated for students and staff.

Welsh Blood Week - Are you #InThe400? In February 2015, the Welsh Blood Service held Welsh Blood Week when we teamed up with Heart Radio to raise awareness of blood donation and the life saving work we do. Every day the aim was to create momentum for 400 people to text BLOOD to 81156 to encourage new donors to come forward.

Two-year-old Ryan featured in our Welsh Blood Week campaign. Ryan requires blood transfusions every 3-4 weeks.

After each transfusion Ryan is like a bottle of pop and full of energy. He is able to go to nursery and have fun. At the opposite end of the scale, when he is due for a transfusion, Ryan can’t stay awake; he has no energy and is prone to infection.

His transfusions are life-saving and without them he would not survive. Ryan’s story was shared as part of our week long activity to promote blood donation and the work we do at the Welsh Blood Service.

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Health Minister and blood donor Mark Drakeford took the time to tweet this message about Ryan and lend his support.

Under the Spotlight - Patient Diagnostics Services

The Patient Diagnostic Services Department at the Welsh Blood Service is the Blood Reference Laboratory for hospitals in South and West Wales.

Providing blood for patients who have developed antibodies as a result of previous transfusions or pregnancies will often prove problematic. The Patient Diagnostics Services Department makes use of numerous different tests to identify the antibodies and provide compatible blood for transfusion, often needed urgently or out-of-hours.

There are no state-of-the-art machines in the Patient Diagnostic Services Department; just many years experience at solving complicated antibody investigations, every sample referred is a problem waiting to be solved! In 2014-15, 1877 samples were referred. During 2014-15, rare antibodies have been detected which required certain donors to be contacted to donate at short notice – the Welsh Blood Service donors never fail us!

Leading Nurse Recognised with AwardWelsh Blood Service Nurse and Educator Ann Richards won a prestigious Royal College of Nursing in Wales Award.

Ann, who is Clinical Training and Development Manager at WBS, won the Nurse Education Award despite fierce competition.

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Ann is a nurse who is also an educator. Her focus is always on donor care, ensuring by practice and example that blood donors’ needs are always met to a very high standard. She has taken the lead on chairing an operational group that scopes, benchmarks, advises, recommends and implements clinical change to enhance donor and product safety and efficiency. In addition, she has introduced a staff information leaflet and an NVQ training package for health care support workers.Ann is an excellent and inspirational role model to all staff. She leads by example and motivates individuals and teams to achieve high standards.

The evening of the awards ceremony at Cardiff’s City Hall was made even more special for Anne by the surprise arrival of her family at just at the right moment to cheer her on and celebrate with her.

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Velindre Cancer Centre – Key

Achievements in delivering excellent services in 2014/15

Welsh cancer patients benefit from improved access to cutting-edge radiotherapy treatment at Velindre Cancer Centre

A project at Velindre Cancer Centre (VCC) to expand Intensity Modulated Radiotherapy Treatment (IMRT) to more patients achieved its target 18-months ahead of schedule.

IMRT uses complex computer imaging to deliver precisely shaped radiation treatments to tumours.The technique minimises damage to healthy tissue surrounding tumours and reduces side effects which can have a lifelong effect on patients’ quality of life. For example, in patients with head and neck tumours IMRT has been proven to reduce damage to salivary glands, reducing the rate of severe dry mouth by more than half. This in turn lessens the rate of swallowing problems which could otherwise involve lifelong tube feeding.

Patient Clive Loebenstein-Peckham, aged 57, from Penarth, received IMRT radiotherapy treatment at Velindre Cancer Centre in 2011 after being diagnosed with inoperable mouth cancer. He said: “The IMRT radiotherapy I received was less invasive and caused far less damage to my body than I was expecting. Velindre Cancer Centre looked after me beyond all expectation – I had a rough time during my treatment but the staff there helped me through it enormously.”

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Derek Ford, aged 59, from Blackwood, had a large tumour at the base of his tongue treated with IMRT radiotherapy at Velindre Cancer Centre in 2010. He said: “Put simply, it cured me. The IMRT minimised the damage to the good bits of my body and did maximum damage to the tumour. The radiotherapy treatment team at Velindre didn’t just give me the treatment – they also supported me through it and showed an amazing level of care for me. It’s great that more and more Velindre patients are benefiting from this treatment when they need it.”

The IMRT programme is supported by funding from the Velindre NHS Trust Charitable Funds, Welsh Government and partner Health boards in Wales. We originally aimed to offer IMRT to at least 35% of Velindre patients requiring radical radiotherapy by October 2016. This successful project means Velindre Cancer Centre provides higher access rates to IMRT treatment than many UK centres.

Dr John Staffurth, a consultant at Velindre Cancer Centre and Clinical Senior Lecturer at Cardiff University’s Institute of Cancer & Genetics, said: “We are grateful to the ongoing support of the Health Boards and Welsh Government as we continue to develop our radiotherapy services for the benefit of our patients.“The success of this programme has been made possible by funds we have received from Velindre Fundraising, so I’d like to thank everyone who generously supports the charity.”

Welsh experts unite in new bid to tackle cancer

Our Chair, Professor Rosemary Kennedy, and the Vice-Chancellor of Cardiff University, Professor Colin Riordan signed an agreement that sets out the basis for closer collaboration between the two organisations. The Agreement shows our commitment to bring together some of Wales’s leading experts in a renewed bid to tackle cancer.

In the UK, one in three people will be diagnosed with cancer in their lifetime and one in four people will die of cancer. Overcoming such an enormous challenge requires a collaborative, multi-faceted approach and this agreement signifies another positive step towards achieving this goal. Signing the new Agreement, Professor Riordan said: "Cardiff University and Velindre NHS Trust are already working to translate world-leading cancer research and innovation into clinical practice.

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This Agreement represents a further commitment to the continuing challenge to find new and effective treatments for cancer. There are great advantages to aligning our work in a more formal and coordinated way. World-leading scientists working alongside frontline clinicians have the potential to deliver the maximum benefit for cancer patients.”

The Agreement builds on existing work between the two organisations. One example is joint research into prostate cancer. Led by Professor Malcolm Mason from Cardiff University’s School of Medicine, this work has successfully translated research into better outcomes for prostate cancer patients.

“When the scientists and clinicians work together it often results in better outcomes for patients,” said Professor Mason. “My work on prostate cancer would not have been possible without the engagement of Velindre's outstanding healthcare and research teams working alongside us in the University, and is an example of what radiotherapy research can deliver.”

Rosemary Kennedy, Chair of Velindre NHS Trust, said: “Many NHS Wales patients have already benefitted from the joint working between Cardiff University and Velinde NHS Trust.”

Celebrating 20 Years of Clinical Trials at Velindre Cancer Centre

In November 2014 patients and staff at Velindre Cancer Centre celebrated 20 years of running clinical trials for patients in Wales.

Twenty years ago just three staff launched the Clinical Trials Unit at Velindre Cancer Centre and it has since grown to such an extent that 34 professionals are now involved in running the unit and supporting patients who take part in trials.

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Since 1994, more than 9,700 Velindre Cancer Centre patients have been recruited to take part in a variety of trials, some of which have contributed to the development of standard cancer treatments. For example, Velindre has participated in trials for drugs including Herceptin (now

routinely used to treat breast cancer) and Abiraterone (one of the standard treatments for prostate cancer).

Alan Buckle, aged 72, from Radyr, who has taken part in part in three clinical trials at Velindre Cancer Centre, said: “You receive first class treatment from all the staff and there is a sense that your are participating in the development of what may be the next approved treatment for your disease.”

Susanne Jones, aged 50, from Barry, was diagnosed with breast cancer in 2006 and this year became the first person in the world to trial a new drug combination which doctors hope could help women with breast cancer.She said: “I had no hesitation signing up for the clinical trial when I was told about it by my oncologist.“Without clinical trials like this one we wouldn’t be able to find the drugs of the future. If a new treatment comes from it then all the better.”

Professor Peter Barrett-Lee, Medical Director of Velindre NHS Trust, joined the Trust in the same year as Velindre NHS Trust opened its doors to clinical trials.He said: “High levels of research activity have helped establish Velindre as a Cancer Centre of Excellence and a number of its clinicians are UK-wide research leaders. The last 20 years have laid a fantastic platform on which to develop a world class service for the next 20 years.”

Velindre Cancer Centre wins NHS Wales Award

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The creation of the first ever emergency cancer service for patients in a South Wales hospital won an NHS Wales Award in July 2014.

The service, which was developed in partnership by Velindre Cancer Centre and Aneurin Bevan University Health

Board, won the ‘Developing A Flexible And Sustainable Workforce’ award.

The new service ensures faster diagnosis and access to a specialist. It was set up following a request from the Welsh Cancer Network to ensure more specialist care was

available for patients suddenly admitted to hospital.Dr Tom Crosby, of Velindre Cancer Centre, said: “This initiative has been excellent for cancer patients, especially to those who have unexpected complications, or previously undiagnosed patients.”

In the first seven months the service was involved in 1,683 cancer-related patient admissions, many of which were identified by the new alert system.

Nicola Davis-Job, Acute Care and Leadership Adviser at the Royal College of Nursing Wales, who judged the award, said: “This is an excellent collaboration between Velindre Cancer Centre and Aneurin Bevan University Health Board, really leading the way for this service in South Wales.”

Velindre research showcased at successful conference

Velindre NHS Trust showcased its important research activities at its Research and Development Conference in October 2014.The Conference concentrated on two main themes – Radiotherapy Research and Early Phase Research.

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Professor Rosemary Kennedy, Chair of Velindre NHS Trust, said: “This conference, and the 30 abstracts that have been submitted for presentation, aims to showcase the diversity of the research across the Trust. Our understanding of disease processes and the development of new therapies is critically dependent on

research.”

Celebrating excellence in NursingVelindre Cancer Centre hosted an ‘Excellence in

Oncology’ nursing conference to celebrate national nurses day in May 2014. The day was attended by more than 50 colleagues from Velindre Cancer Centre and Health Boards around Wales.

Feedback received following the conference included:

- “Whenever I think or hear of Velindre after today , I will think of all you amazing people and the wonderful work you do . We have always had good reports from patients and relatives who have attended … Thank you.”

“Very inspirational day. It made me proud to work in such a wonderful place as Velindre. I feel humbled by the whole day.”

Free Wi-Fi for patients and visitorsPatients and visitors are now able to surf the internet for free at Velindre Cancer Centre, thanks to a new Wi-Fi system launched in November.

WiFi is already making a huge difference to patients’ time spent in the Cancer Centre, allowing them to use their own smart phones, tablets and laptops to keep in touch with friends and family, check emails or download movies, and much more.

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This service has been driven directly by patients, who requested access to the Internet through our Patient Experience Surveys. It was therefore extremely pleasing to officially launch the Public Internet with a Velindre Fundraising group who donated the money to finance this initiative. The group of 8 friends climbed Mount Kilimanjaro and raised an incredible £44,000.

Radiographer of the YearOne of our Radiographers, Clare Beswick, has been awarded the prestigious Welsh Radiographer of the Year accolade. Clare was nominated by her peers for her selfless, tireless approach to patient care and staff support. She was presented with her award at the Society of Radiographers Radiography Awards in London.

Top of the classThe South Wales Oncology Training Programme has received outstanding results following a General Medical Council training survey in 2014.

The programme, which is run by Velindre Cancer Centre and South West Wales Cancer Centre in Swansea, received the best results in the UK. This is down to the hard work all educational supervisors, clinical supervisors, training consultants and other consultants put into training. The survey results show how well trainee doctors are supported and demonstrate the quality of the training they receive.

Excellence Award for Teaching TeamCardiff University’s School of Medicine gave four Velindre Cancer Centre staff an ‘Excellence Award’ for Best Undergraduate Team due to their work teaching and supporting students.The Award was presented to Dr Alison Brewster; Emma Harrett; Rhiannon Jenkins and Angela Voyle-Smith in recognition of the excellent support they have provided to Year 3 medical students.

Prestigious award for Velindre Doctor Dr Jason Webber, from Velindre Cancer Centre, was awarded a 5-year career development fellowship from Prostate Cancer UK.

Dr Webber’s application was based on research studies of prostate cancer carried out at Velindre Cancer Centre. This fellowship is one of only 2 or 3 to be funded in the entire UK.

Five Star Cuisine at Velindre Cancer CentreIn September 2014 the Velindre Cancer Centre restaurant for patients, visitors and staff was assessed by the Food Standards Agency and achieved a food hygiene rating of 5 out of 5.This is a fantastic achievement and is testament to the staff within the catering function.

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Fundraising

The Velindre NHS Trust Charitable Funds has reported an income for the last 12 months of £2.9 million – money which will all go towards providing excellent facilities and improving patient care at Velindre Cancer Centre. For further information in relation to Fundraising and Charitable funds please click on the link to the Velindre NHS Trust Charitable Funds Annual Report 2014/15. http://www.wales.nhs.uk/sitesplus/972/page/55185Please note that our Charitable Funds Annual Report will not be published until October 2015. A link to the report will be available at the above link once it is published.

Caring for our Staff

Patients, donors, carers and their families are at the centre of everything we do and their needs can only be met if we are able to create an environment which supports our staff in achieving their potential.

To demonstrate our commitment to caring for our staff the Trust has signed up to the ‘NHS Wales Staff Health and Wellbeing Charter’. To improve the health and wellbeing of our staff we strive to:

Work together to encourage healthier lifestyles and life choices

Ensure that all staff with health problems are supported in the workplace

Make sure managers understand the importance of sympathetic support to staff both in work and for those who are absent due to ill health.

Promote the effective management of sickness when staff are prevented from attending work through ill health or are at risk of having to take sick leave.

Support and promote work/life balance though a range of flexible working arrangements and initiatives

Ensure staff have access to relevant forms of support (eg. Occupational Health, Employee Assistance Programme etc)

Run staff events and offer information on a wide range of healthy lifestyle topics Ensure our staff are appropriately trained, supervised and supported in their role Provide a regular performance review mechanism (appraisal) for all staff Encourage staff to create new health promotion and prevention initiatives and

ideas.

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Trust Signs Up To Mental Health Charter To Support Employees

We have signed up to the ‘Charter For Employers Who Are Positive About Mental Health’ to support our staff.

The charter is part of the UK-wide ‘Mindful Employer’ initiative which is aimed at increasing awareness of mental health at work and providing support for businesses in recruiting and retaining staff.

By signing up to the charter the Trust is showing its commitment to improving the working lives of staff.

Steve Ham, Interim Chief Executive of Velindre NHS Trust, said: “We recognise that with the right support, people with mental health issues are able to stay in work and can continue to contribute successfully.

“We are pleased to be able to show our dedicated commitment in this area by signing up to the Mindful Employer Charter.”

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Velindre NHS TrustAnnual Governance Statement

2014/15

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Darparu ansawdd, gofal a rhagoriaeth

Annual Governance Statement 2014/15

Scope of Responsibility

Velindre NHS Trust provides specialist services to the people of Wales. The operational delivery of services is managed through Velindre Cancer Centre and the Welsh Blood Service. The Director of Velindre Cancer Centre and the Director of Welsh Blood Service are directly accountable to the Velindre NHS Trust Chief Executive.

Specialist cancer services for South East Wales are delivered by Velindre NHS Trust using a hub and spoke model. The hub of our specialist cancer services is

Velindre Cancer Centre. This is a specialist treatment, teaching, research and development centre for non-surgical oncology. We treat patients with chemotherapy, Systemic Anti-Cancer Treatments (SACTs), radiotherapy and related treatments, together with caring for patients with specialist palliative care needs.

The Welsh Blood Service plays a fundamental role in the delivery of healthcare in Wales. It works to ensure that the donor’s gift of blood is transformed into safe and effective blood components which allow NHS Wales to improve quality of life and save the lives of many thousands of people in Wales every year.

The Board is accountable for Governance, Risk Management and Internal Control for those services directly managed and those managed via hosting arrangements. As Accountable Officer and Chief Executive of the Board, I have responsibility for maintaining appropriate governance structures and procedures as well as a sound system of internal control that supports the achievement of the organisation’s policies, aims and objectives, whilst safeguarding the public funds and this organisation’s assets for which I am personally responsible. These are carried out in accordance with the responsibilities assigned by the Accounting Officer of NHS Wales.

The Trust also hosts the following organisations on behalf of other bodies;

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Delivering quality, care & excellence

NHS Wales Informatics Services (NWIS) NWIS operates under the direction of the Deputy Director, Digital Health and Care of the Welsh Government and is responsible for both the strategic development of Information Communications Technology (ICT) and the delivery of operational ICT services and information management. NWIS has a national remit to support NHS Wales, make better use of scarce skills and resources, and facilitate a consistent approach to health informatics and the implementation of common national systems. The Director of NWIS is accountable to the Deputy Director, Digital Health and Care of the Welsh Government and is also bound by a Statement of Internal Control for governance compliance with the Velindre NHS Trust Chief Executive.

NISCHR Clinical Research Centre (NISCHR CRC) The National Institute for Social Care and Health Research Clinical Research Centre (NISCHR CRC) brings together all-Wales research networks in health and social care and cancer. The Director of NISCHR CRC is held accountable by NISCHR Welsh Government for the delivery and performance of services. The Trust Chief Executive ensures the Trust provides appropriate governance support via a formal Hosting Agreement.

During 2014-2015, the Trust submitted a proposal to NISCHR Welsh Government to host the new ‘NISCHR Workforce’ organisation with effect from 1st April 2015. The proposal was accepted and the Trust established a Transition Board to manage the process of organisational change and ensure appropriate governance arrangements will be in place. A Hosting Agreement will be in place between Velindre NHS Trust and NISCHR Welsh Government, together with a Memorandum of Internal Control for the Responsible Officer of NISCHR Workforce.

National Collaborating Centre for Cancer (NCC-C) The NCC-C was established in April 2003. The centre is funded and commissioned by the National Institute for Health and Care Excellence (NICE) to develop evidence-based clinical guidelines for the NHS in England, Wales and Northern Ireland on treating and caring for people with cancer. The Director of NCC-C is held accountable by NICE for the delivery and performance of services. The Trust Chief Executive ensures the Trust provides appropriate governance support via a formal Hosting Agreement.

During 2014-2015, the Trust established a Project Board to oversee the development of a bid to NICE to host one of two new Guideline Development Centres for the UK. If successful, the Trust would provide the new centre from the 1st April 2016, and will ensure appropriate governance structures are in place.

NHS Wales Shared Services Partnership (NWSSP)

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On 11th May 2012, the Velindre National Health Service Trust Shared Services Committee (Wales) Regulations 2012 No.1261 (W.156) was laid before the National Assembly for Wales and came into force on 1st June 2012. The NWSSP is a dedicated organisation that supports the statutory bodies of NHS Wales through the provision of a comprehensive range of high quality, customer focused support functions and services.

NWSSP is hosted by Velindre NHS Trust via a formal Hosting Agreement, signed by each statutory organisation in NHS Wales. The Director of NWSSP holds Accountable Officer status and holds a separate Accountability Statement with the Director General for Health in the Welsh Government.

The Trust’s Assurance Framework

This Annual Governance Statement details the arrangements in place for discharging the Chief Executive’s responsibility to manage and control Velindre NHS Trust’s resources, and the organisations which it hosts, during the financial year 2014/2015.

Due to the unique Accountable Officer status of the Director of Shared Services Partnership (NWSSP) an Annual Governance Statement for NWSSP has been requested and submitted from the Director of NWSSP to the Velindre NHS Trust Chief Executive.

The Directors from the other bodies hosted by Velindre NHS Trust (1.1 – 1.3 above) have signed and submitted a ‘Statement of Internal Control’ detailing and declaring compliance with Velindre NHS Trust governance arrangements which is submitted at the end of March each year to the Velindre NHS Trust Chief Executive to provide assurance that Trust policy, systems and processes are being complied with to support good governance.

Discharging ResponsibilitiesThe Board has been constituted to comply with the National Health Service Wales, Velindre NHS Trust (Establishment) Order 2002 No. 442 (W57). In addition to responsibilities and accountabilities set out in terms and conditions of appointment, Board members also fulfil a number of Champion roles where they act as ambassadors for these matters.

The Board discharges its responsibilities through its Committees (listed in the table below) and scheme of delegation which is set out in our Standing Orders.

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There are 8 Committees, reporting directly to the Board which are supported by sub-Committees/groups in the discharge of functions;

Committee Sub Committee

Quality & Safety Committee Trust Organisational Learning Committee

Audit Committee (including 5 separate meetings of the “Audit Committee- for Shared Services” to consider NHS Wales Shared Services Partnership (NWSSP) Matters)

Charitable Funds Committee Investment Performance Review Sub-Committee

Research & Development Committee Research Risk Review Committee

Genetic Modification Sub Committee

Information Governance & IM&T Committee

Remuneration Committee

Workforce & Organisational Development Committee

Planning & Performance Committee

Each Committee of the Board produces an Annual Report for the Board on Committee activity which details Committee attendance for all Members and attendees. Committee Annual Reports are included in the Trust Board papers following the relevant reporting year end and are available on the Trust website or from the Trust Secretary.

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BOARD MEMBER NAME POSITION AREA OF EXPERTISE BOARD COMMITTEE MEMBERSHIP CHAMPION ROLES

Professor Rosemary Kennedy

Chair Partnerships & Collaboration (Chair) The Board(Chair) Remuneration Committee(Chair) Charitable Funds Committee

Janet Pickles Independent Member Quality & Safety (Chair) Quality & Safety Committee

Charitable Funds CommitteeInfection Control, Patient Experience,Older Persons

Professor Jane Hopkinson

Independent Member University Representative Research & Development Committee Research

Harry Ludgate Independent Member Information Governance & Information Management and Technology

(Chair) Information Governance & IM&T Committee(Chair) Workforce & OD CommitteeAudit CommitteeRemuneration Committee

Information & Workforce

Paul Griffiths Independent Member Finance (Chair) Audit CommitteeRemuneration CommitteeQuality & Safety CommitteePlanning & Performance CommitteeCharitable Funds Committee

Veterans

Phil Roberts Independent Member Estates (Chair) Planning & Performance Committee(Chair) Research & Development Committee Audit CommitteeInformation Governance & IM&T Committee

Design, Sustainability and Welsh LanguagePublic & Patient Involvement

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BOARD MEMBER NAME POSITION AREA OF EXPERTISE BOARD COMMITTEE MEMBERSHIP CHAMPION ROLES

Judge Ray Singh Independent Member Legal Remuneration CommitteeWorkforce & OD CommitteePlanning & Performance Committee

Violence & AggressionSafeguarding Putting Things Right

Steve Ham Interim Chief Executive

Executive Director of Finance (until 4.1.2015)

Charitable Funds Committee Not applicable

Mark Osland Interim Executive Director of Finance.(From 5.1.2015)

Charitable Funds Committee Not applicable

Professor Peter Barrett-Lee

Executive Medical Director

Research & Development Committee Not applicable

At a local level, the Trust has agreed Standing Orders (SOs) for the regulation of proceedings and business. The Trust SOs are designed to translate the statutory requirements set out in the National Health Service Trusts (Membership and Procedures) Regulations 1990 (1990/2024) into day to day operating practice, and, together with the adoption of a scheme of matters reserved to the Board; a scheme of delegations to officers and others; and Standing Financial Instructions, they provide the regulatory framework for the business conduct of the Trust and define - its 'ways of working'. These documents, together with the range of policies set by the Board make up the Governance and Accountability Framework. The Standing Orders have been periodically updated to account for alterations in year and were last reviewed, updated and approved by the Trust Board in January 2015 and March 2015 as outlined in section 3 on page 11.

In January 2015, Professor Rosemary Kennedy was re-appointed by the Minister for Health & Social Services as Chair of Velindre NHS Trust for another four year term following her initial appointment in January 2011.

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The substantive Chief Executive is seconded to Welsh Government until at least the end of September 2015. The substantive Executive Director of Finance has been appointed as the Interim Chief Executive Officer until at least the end of September 2015. The substantive Chief Executive Officer retained Accountable Officer status until the appointment of an Interim Executive Director of Finance on the 5 th January 2015. This appointment now allows the Interim Chief Executive to assume the full responsibilities of the Chief Executive Officer including Accountable Officer Status.The following table outlines dates of Board and Committee meetings held during 2014/15; All meetings were quorate except for the following occasions:

The Research & Development Committee was not quorate for one item at its January 2015 and March 2015 meeting as a member of the Committee declared an interest and left the meeting whilst the item was discussed. The item was circulated to other Board members for approval out of Committee.

Board/Committee Period 1st April 2014-31st March 2015

Trust Board 5th June (including the AGM)

31st July 2nd October 4th December 29th January 26th March

Audit Committee 29th April 3rd June 2nd July 7th October 17th December 25th FebruaryAudit Committee for Shared Services 9th April 3rd June 28th July 19th November 4th FebruaryCharitable Funds Committee 16th April 8th July 25th September 26th November 11th FebruaryQuality & Safety Committee 12th June 4th September 11th December 5th March

Planning & Performance Committee 21st May 15th July 17th September 11th December 14th January 11th March Information Governance & IM&T Committee

8th May 14th August 18th November 24th February 27th March

Research & Development Committee 1st May 24th July 30th October 27th January * 3rd March Workforce & Organisational Development Committee

13th May 7th August 6th November 10th February

Remuneration Committee 5th June (including the AGM)

31st July 2nd October 4th December 29th January 26th March

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At six month intervals the Audit Committee receives a ‘governance pack’ from NWIS providing a specific focus on the key aspects of assurance in relation to the hosted organisation.

Committee Activity

Each Committee formally reports annually to the Trust Board on its work during the year detailing the business, activities, attendance and main issues dealt with by the Committee in the reporting year. Copies of the Committee Annual Reports are available within Board papers on the Trust’s website or from the Trust Secretary.

In addition, each Trust Board meeting receives a highlight report outlining the issues and activity considered and addressed by each Committee at its last meeting. These highlight reports are presented to the Board by the Independent Member Committee Chair. The highlight reports are available within Board papers on the Trust’s website or from the Trust Secretary. The Terms of Reference for each Committee are reviewed annually in line with the Trust Standing Orders, or more frequently if deemed necessary by the Committee or Board. The Terms of Reference for all Committees are available from the Trust Secretary.

The Audit Committee has developed a mechanism by which it can evidence the discharge of its duties on behalf of the Board through a ‘Committee Assurance Schedule’ which is based on the Terms of Reference and delegated powers.

In May 2014, Internal Audit reviewed the clinical audit department, the audit report highlighted that the department had a well- defined structure and quality framework consistent with the provision of a high quality service. The report noted the need to ensure closer links with the Trust Quality and Safety Committee and Trust Audit Committee to ensure alignment of key assurance and improvement processes. In response to this review the Trust reviewed its processes and agreed a Clinical Audit Assurance Framework, clearly detailing the role of the Audit Committee and Quality & Safety Committee in assuring the Board in relation to Clinical Audit activity.

In support of the Board, the Trust also has a Local Partnership Forum that met 5 times during 2014/2015, with Joint Chairs who are each nominated from the staff representatives and Executive Directors. The role of the Local Partnership Forum is to supply the main (but not only) forum within the Trust where the Directors of the Trust and Trade Union Representatives can discuss together and develop appropriate directions and responses to all major service development and change management issues.

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Key highlights of issues considered by the Trust Board and its Committees during 2014/2015 include;

Strategic Outline Programme - Transforming Cancer Services in South-East Wales. Establishment of an All Wales Blood Service by 2016. Consideration and approval of the Integrated Medium Term Plan (IMTP). Consideration and approval of the Clinical Audit Annual Report & Clinical Audit

Assurance Framework. Approval and sign off of the Annual Accounts for the Trust and Charity. Consideration and approval of the Research & Development Strategy. Receipt of the Wales Audit Office Annual Audit Letter. Consideration and action taken in respect of the outcome of the Wales Audit Office

Structured Assessment. Consideration of the outcome and actions planned in response to the Fundamentals

of Care Audit. Consideration of implications to Velindre NHS Trust of ‘Trusted to Care’ Report. ‘Good Governance Guide for NHS Wales Boards’ for adoption by all Trust and Health

Boards in Wales. Introduction of a new ‘Communications and Engagement Strategy 2014-17’. The outcome of Patient Experience Surveys at Velindre Cancer Centre. Information Governance and IM&T Delivery Plans 2014 – 2017. Annual Palliative Care Report – the first Annual Palliative Care Report was received

which set out the range of work that has been undertaken by Velindre Cancer Centre.

Blood Establishment Computer Software (BECS) Implementation programme within the Welsh Blood Service.

Monitoring and consideration of the Integrated Quality Performance Story Board – which provides stakeholders with a clear view of service quality and performance.

Research and Development business cases to support the Trusts Research Strategy, to include the appointment of an Assistant Director of Research & Development.

Business Cases to support the delivery of quality, safe services to the population we serve.

Minutes and papers of all Board meetings are published on the Trust Internet site via the following link: Trust Board Papers and Minutes

During 2014/2015, key aspects of Board business and issues delegated to the Audit Committee for consideration and advice, including action taken included;

Agreement of the Internal and External Audit Plans for the year. Receiving Internal and External Audit Reports and subsequently monitoring progress

against Audit Action Plans. Agreeing the annual counter fraud plan and monitoring counter fraud activities.

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Regular review of the register of gifts and hospitality. Monitoring the development and draft content of the Trust’s Annual Governance

Statement. Sign Off of Trust Annual Accounts, as delegated by the Trust Board. Monitoring of Governance Arrangements across the organisation, including hosted

bodies. Monitoring overall risk management process by reviewing the Trust Risk Register at

each meeting.

Matters relating to quality and safety activity during 2014/2015 are highlighted in the Trusts Annual Quality Statement appended to the Trust’s Annual Report and available on the Trust Internet site via the following link: Velindre NHS Trust Annual Report from the end of September 2015.

Engagement with the Local Partnership Forum

Examples of engagement with the Local Partnership Forum during 2014/2015 are:

Establishment of an All Wales Blood Service – the Trust is working towards establishment of an All Wales Blood Service by 2016

E- Expenses Project – system for electronically submitting expenses claims, removing the paper system.

Electronic Staff Record (ESR) – Self Service Implementation - ESR Self Service enables every member of Velindre NHS Trust staff to view and maintain their own records and to instigate actions that will improve their personal development.

Pennies from Heaven - The Pennies from Heaven Scheme offers staff an opportunity to donate their odd pennies from their salary/wages to collectively raise pounds for a registered charity, which has been chosen by Velindre NHS Trust.

Health & Wellbeing Charter - Working together, NHS staff and managers can design products and interventions that support the workforce, to maximise their wellbeing and in addition allow them to become role models for the population of NHS Wales by modeling healthy lifestyle choices.

Strategic Outline Programme - Transforming Cancer Services in South-East Wales Transfer of Undertakings (Protection of Employment) (TUPE) transfers for staff out

and into other NHS Wales Organisations. Blood Establishment Computer Software (BECS) Implementation programme within

the Welsh Blood Service. Integrated Medium Term Plan (IMTP) - the achievement of the vision and strategic

objectives of the Trust is driven by the Integrated Medium Term Plan (IMTP), which sets out the priorities and actions that will be delivered on a rolling 3 year basis

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Board Development and Effectiveness

In addition to Trust Board and Committee meetings, the Board holds regular development sessions covering all aspects of corporate responsibility. The Trust Board Enabler Sessions are open to all Board Members and attendees including Community Health Council representatives, staff representatives and patient representatives as well as other relevant groups depending on the topic being covered. During 2014/2015, the Board held sessions on the following topics;

NHS Wales Shared Services Partnership Annual Review Older Peoples Commissioner – Dignified Care Andrews Report – Trusted to Care Wales Audit Office (WAO) Structured Assessment Feedback Equality & Diversity Training – Public Sector Duty

The Trust Secretary has continued to work with agencies such as Academi Wales to design a Board development programme to be delivered during 2015-2016. Other areas being progressed during 2014-2015 include;

Transparency - The Trust continues to focus on improving the timeliness of publication of papers, being mindful of ensuring compliance with data protection and other information governance requirements. In November 2014, the Trust Secretary commenced engagement on the development of “Business Standards for the Management of Trust Board & Committee Meetings”, the guidance which will be fully implemented for 2015-2016 will further support the requirement for clear, concise and timely information equipping Boards and Committees to make decisions and be appropriately informed and assured in relation to the business of the Trust.

Committee Self Assessment - These self assessments are maturing and the Audit Committee led the way in piloting a new approach to evidence the discharging of the delegated functions via a ‘Committee Assurance Schedule’. It is envisaged that this approach will be rolled out to all Committees to aid the self assessment process.

Board Development - One of the key outcomes of the Trust Board self assessments is to ensure an effective Development Programme is in place to support individual Board Members and the Board as a whole. The Trust Board Enabler Sessions are well received and a programme is developed on an annual basis covering topical issues and identifying sessions that would enhance the Boards learning. The additional support and guidance from Academi Wales for 2015-2016 will further support individual and collective performance of the Board.

Organisational Values – Work is progressing to strengthen and formalise core organisational values for the Trust to support the Standards of Behaviour Framework

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and set standards of expectation for all staff on what they can expect from Velindre NHS Trust as their employer and what we expect from them. The Development and Implementation of Organisational Values is being led by the Executive Director of Workforce & Organisational Development with implementation planned for 2015-2016.

Hosted Organisations - The Trust Secretary is reviewing the current arrangements in place for all organisations hosted by Velindre NHS Trust with a view to improving consistency of approach in relation to governance frameworks in place for hosting organisations on behalf of other NHS bodies.

Velindre NHS Trust Standing Orders and Standing Financial Instructions

The Trust approved a revised set of Standing Orders for the regulation of proceedings and business in the January 2015 and again in March 2015, in relation to;

January 2015;

A review to ensure all relevant Trust policies reflected the delegations and procedures as set out in the Standing Orders (SO’s) and Standing Financial Instructions (SFIs).

Proposed change to the financial limits governing the procurement of pharmaceuticals.

March 2015;

A change to reflect the reference to appropriate job roles in the new NISCHR Workforce Organisation from the 1st April 2015.

Removal of references to hosted organisations that are no longer hosted by Velindre NHS Trust.

Clarification of the definitions determining the financial limits awarded to NWIS within the Trust’s SO’s distinguishing between ‘Programme Expenditure’ and ‘Operational Expenditure’.

Board Appointments during 2014-2015

The Trust made the following appointments to support the Executive Team:

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In May 2014, the Trust appointed an Assistant Director of Informatics to support the Information Management & Technology and Information Governance agenda within the Trust.

In August 2014, the Trust welcomed a new Executive Director of Organisational Development and Workforce, who immediately initiated a review of the Workforce and Organisational Development structure to ensure it was fit for purpose.

To further strengthen the Trust’s Planning and Performance function the Trust appointed an Assistant Director of Planning and Performance in September 2014.

In October 2014, an Assistant Director of Research & Development was appointed to oversee Research and Development activity in the Trust and drive the development and delivery of the Trust’s Research & Development Strategy.

In January 2015, the Trust welcomed a new Assistant Director of Organisational Development who will initially support the Executive Director in the structural review of the workforce and organisational development function.

In January 2015, the Trust welcomed an Interim Director of Finance, please refer to note on page 29. The substantive Director of Finance has been appointed as the Interim Chief Executive Officer until at least the end of September 2015. The substantive Chief Executive Officer retained Accountable Officer status until the appointment of an Interim Director of Finance. This appointment now allows the substantive Director of Finance to assume the full responsibilities of the Chief Executive Officer including Accountable Officer Status in an interim capacity following the secondment of the substantive post holder to Welsh Government.

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 risks; it can therefore only provide reasonable and not absolute assurances 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, 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 for the year ended 31 March 2015 and up to the date of approval of the 2014/2015 annual report and accounts.

The Welsh Government requires that the Trust operates within the wider governance framework set for the NHS in Wales and incorporating the standards of good governance set for the NHS in Wales (as defined within the Citizen Centred Governance principles and Standards for Health Services in Wales), together with its planning and performance management frameworks.

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ASSURANCE FRAMEWORK

Non Executive(Independent Member)

Executive

Committees CE

Executive Management Board

PlanningDeliveryPerformanceReporting

VCCSMT

 

WBS SMT

BOARD

CFC * W&OD Audit R&D ** IM&T P&P Q&S Rem

AssuranceAdviceStrategic Oversight‘Champion’ RoleBoard Member Agreement

Investment Performance

Sub Committee

Trust Organisational Learning Committee

Genetic Modification Sub CommitteeResearch Risk Review Sub Committee

Organisational ObjectivesStrategyScrutinyPrioritiesStandardsGovernance

3 Yr PlanObjectivesDelivery PlansDelivery & Performance Management.Organisational DevelopmentAuditRisk Management & Risk Register.

Quality Measurement Framework

The Trust’s Internal Control (Assurance) Framework

An overarching summary of the Trust’s Internal Control (Assurance) Framework is illustrated below;

Please note that the following diagram aims to address the Assurance Framework for the directly managed services of the Trust.

* CFC constitutes Executive and Independent Members as each are members in their role as Trustees of the Velindre NHS Charity** R&D Committee includes an Executive Director who is a member of the Committee.

Governance of the Charitable Funds

The Velindre NHS Trust Board was appointed as Corporate Trustee of the Charitable Funds by virtue of the Velindre National Health Service Trust (Establishment) Order No. 2838 that

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came into existence on 1st December 1993, and its Board serves as its agent in the administration of the charitable funds held by the Trust.

The Trust Board as Corporate Trustee is ultimately accountable for charitable funds donated to Velindre NHS Trust. In order to facilitate the administration and management of these funds the Trust Board has established a Charitable Funds Committee (CFC) to provide advice and recommendations to the Board. Committee meetings are held every three months and otherwise as the Committee Chair deems necessary, at least two members must be present to ensure the quorum of the Committee.

The CFC is supported by the Charitable Funds Operational Management Group, which was established early in 2011 to strengthen the governance arrangements by monitoring the operational application and management of all Charitable Funds held within the Velindre NHS Trust. The CFC is also supported by an Investment Performance Review - Sub Committee, to oversee the investments made by the Charity. Further information in respect of the Charitable Funds is available in the Trustee’s Annual Report which can be accessed via the Charitable Funds page on the Trust internet site or by clicking here: Trustee Annual Report.

Hosted Organisations Systems of Internal Control and Assurance

Aside from the NHS Wales Shared Services Partnership Committee, hosted organisations utilise the existing Trust’s Committee Structure illustrated above. A separate Velindre NHS Trust Audit Committee is held to consider issues relating specifically to NWSSP at least four times a year, having the same Chair and Independent Membership as the Velindre NHS Trust Audit Committee. Information relating to the governance arrangements in NWSSP is contained within the Director’s Annual Governance Statement to the Velindre NHS Trust Chief Executive which is on the Trust’s website: www.velindre-tr.wales.nhs.uk

NWSSP has a ‘NHS Wales Shared Services Partnership Committee’ which was established as a sub-committee of Velindre NHS Trust Board in 2012 to comply with Ministerial Directions. The NWSSP Committee has membership from each statutory body in NHS Wales, and is chaired by an Independent Chair. The NWSSP Committee reports to Velindre NHS Trust Board and all other health body Boards in Wales via their representative member on the Committee. NWSSP have their own Standing Orders which are appended to the Velindre NHS Trust Standing Orders.

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Currently, all organisations hosted by Velindre NHS Trust link with Board Committees and Management Groups to ensure assurance is provided for the governance arrangements including statutory compliance for the areas remaining within the Trust’s area of responsibility.

Responsible Officers from all organisations the Trust hosts are required to complete and sign a declaration of compliance statement which in turn supports the Chief Executive to sign the Trust Annual Governance statement, as outlined on page 3, section 2, ‘The Trusts Assurance Framework’.

Capacity to handle risk

The Trust has an approved Risk Management Policy in place. The Policy details a robust risk assessment process to identify, assess and manage organisational risks which are reported on a risk register, to the Trust Board. The Trust Board is ultimately responsible for overseeing the Trust’s risk register and holding the Executive to account for ensuring management action is taken to minimise risk. The Board delegate’s responsibility to the Trust’s Quality & Safety Committee for overseeing the risk management process and the Trust’s Audit Committee retains the oversight to ensure the system of risk management is effective.

The organisations hosted by Velindre NHS Trust maintain and manage their own risk registers and comply with the Trust escalation processes to ensure the Board are made aware of any significant relevant risks via the Trust Risk Register as necessary. Risks relating to hosted organisations will only be escalated to the Velindre NHS Trust risk register where matters directly affecting the Trust are apparent. Matters relating to service delivery and performance are a matter for sponsor bodies to receive, manage and report as necessary.

Risks that have been managed and removed from the Trust Risk Register during 2014-2015 include;

Legislative Requirement to test three mandatory markers – within the Welsh Blood Service there was a project in place to secure funding to manage the improved resilience of the system to ensure continued compliance with legislative requirements. Removed December 2014.

ABO and Rhesus D group, red cell antibody screening and phenotyping – within the Welsh Blood Service there was a project in place to secure funding and manage planned replacement of two blood testing systems that were no longer in a serviceable condition. Removed December 2014.

No defined timescales in respect of Cansic Trak interface availability - there was a risk to the Trust that when Cardiff & Vale Health Board 'went live' there would be no

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direct electronic feed of pathology results into Canisc/Chemocare. Fortunately when Cardiff & Vale ‘went live’ the interface was ready for Velindre Cancer Centre which ensured that the Trust continued to receive pathology test results electronically in Canisc, on this basis this risk was removed from the Trust Risk Register in December 2014.

See new risk below in relation to Nuclear Acid Testing Contract which was also removed from the risk register on the 31st March 2015.

New risks identified during 2014-2015 and continue to be managed include;

Legal challenge to the Nucleic Acid Testing (NAT) Testing contract procurement award that was led by NHS Blood and Transplant (NHSBT) for UK Blood Services- Formal legal proceedings instigated by a supplier against sections of the NAT tender award. Added November 2014, Closed on 31st March 2015 as new procurement exercise is now underway.

As at the 31st March 2015, the main significant risks on the Trust’s risk register included;

Constraints arising from limitations of estate capacity at the Velindre Cancer Centre Site. To mitigate this risk the Trust is undertaking the following actions:

o An accommodation review of clinical and administrative facilities at Velindre Cancer Centre.

o Following Welsh Government approval of the Trust’s Strategic Outline Programme (SOP), which conveyed the Trust’s ideas on how cancer services in South East Wales could look in the future, the Trust, is leading the programme for “Transforming Cancer Services in South East Wales”.

System management for maintaining water systems at main and peripheral service sites. To mitigate this risk the Trust is undertaking the following actions:

o Risk assessments have been completed for all sites.o A review of the Policy in respect of Water Management o A review of the building lease contracts with sites not owned by the Trust.

Further information on how risks are being managed and mitigated is detailed in the Trust Risk Register which is received by the Trust Board. Trust Board papers are available on the Trust Internet site, via the following link: Trust Board Meeting Papers.

Risk Management

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The process by which the Trust manages risk is detailed in the Trust’s Risk Management Policy, which is available upon request from the Trust Secretary or via the Trust’s Intranet Site.

The overall aim of the Trust’s Risk Management approach is to progress a comprehensive risk management programme to ensure that: -

There is compliance with statutory legislation All sources and consequences of risk are identified Risks are assessed and either eliminated or minimised Damage and injuries are reduced, and people’s health and well-being is optimised Resources diverted away from patient/service user care to fund risk reduction are

minimised Lessons are learnt from concerns in order to share best practise and prevent

reoccurrence

The Trust has a series of controls in place to manage and mitigate these risks.

I, as Accountable Officer for the Trust, have overall accountability and responsibility for having an effective risk management system in place within the Trust, including hosted organisations. I am responsible for meeting all statutory requirements and adhering to guidance issued by the Welsh Government Department of Health & Social Services in respect of governance. Within the Trust’s Risk Management Policy, I have set clear measurable risk management objectives for the Executive Directors and Service Directors with delegated responsibility for risk management and governance.

The Executive Director of Nursing & Service Improvement has lead responsibility to the Chief Executive and the Board for risk management. Each Executive Director is responsible for managing risk within their area of responsibility and Executive Directors are supported in these duties by the Service Directors and Senior Managers across the organisation.

Every member of staff, including clinicians, is responsible for ensuring that their own actions contribute to the wellbeing of patients/service users, staff, visitors and the organisation. They are expected to contribute to the identification, reporting and assessment of risks and to take positive action to manage them appropriately. The Trust has implemented the All Wales Raising a Concern (Whistleblowing) Policy which is available on the Trust intranet site. The policy is in place but has not been utilised during 2014-2015.

Risk management is embedded in Trust decision making and service delivery. This is supported by continually considering and assessing Trust compliance with key clinical guidance including:

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Guidance and technology appraisals from the National Institute for Health and Care Excellence (NICE)

National Service Frameworks (NSFs) National Enquiries for example Confidential Inquiries Patient Safety Alerts Professional Guidelines for example from Royal Colleges Guidelines or standards from other national /local bodies Local and national audit Research & Development Participation in clinical trials.

The organisation’s risk profile is visible through the Trust Risk Register. Risks are identified at the commencement of new or amended activities and through the ongoing review of existing risks. Risk assessments are undertaken to assess the impact upon the service and other stakeholders. Public Stakeholders are involved in the assessment of risk through public consultations, Patient Liaison Group representation at Board and Committee meetings, feedback received in respect of Patient Experience surveys and Donor Forums and learning from Concerns received from patients, donors, relatives and/or carers.

All risks are assessed and awarded a score, relating to impact and likelihood. Risks are escalated, resulting in the highest level of risk (score 12 or above) being referred to the Executive Management Board where a collective appraisal will be made of the risk, after which time, the risk will be entered on to the Trust’s risk register and reported to Trust Board and relevant Board Committee/s. Each risk entered onto the Trust register is given a ‘target’ score dependent upon the appetite for the risk, which is the level of risk the Trust Board is prepared to accept before action is deemed necessary to reduce it. This will be applied in decision making to inform the prioritisation of actions and the resources required to mitigate risks on the Trust risk register.

The Trust delivers a programme of risk assessment training for all staff and managers responsible for undertaking risk assessments.

Mitigation actions are in place for all risks identified and actions plans have been developed to reduce risks to an accepted level.

Each risk on the Trust risk register is assigned to an assuring Committee of the Board to enable in-depth monitoring of management action in relation to specific risks. Risks are also monitored and reviewed monthly by the Executive Management Board and all risks are routinely reported quarterly to the appropriate Committee and the Board. The Audit Committee oversees that the risk management system in place is effective. Importance of

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maintaining an open and active dialogue on risks throughout the organisation is an approach that the Trust has cultivated.

During 2014-2015 improvements were made to the risk register in respect of the processes used to report and monitor risks by the Board. A review of the Risk Management Strategy was initiated in 2014-2015 and will be approved and implemented in 2015-2016. A Board session is being held in 2015-2016 to determine the Board’s risk appetite.

The Trust’s risk register is published in the Trust Board Meeting papers published on the Trust Website detailing the organisations top risks, and the controls in place to manage those risks. The register is dynamic and reviewed continuously throughout the year. The Board acknowledges that a continued focus on management and assurance processes during 2015-2016 will strengthen confidence that the Board are sighted on the right risks at the right time and can report transparently on actions to manage and mitigate organisational risks.

Risk Management and risk resourcing is managed by Divisional Directors through their business plans. All divisions /departments have process for assessing risk and risk registers are created as appropriate. Risks are updated and reviewed within the service division. The divisional senior management teams (SMT) work with their supporting groups/ Committees to ensure effective controls are in place for their risks to be managed at a tolerable level.

Risks are referred to the appropriate Committees of the Board to consider them and identify additional control measures. In turn, the Committees provide assurance to the Trust Board that all reasonably practicable steps have been taken to reduce the risk, that effective controls are in place and the risk is being managed at a tolerable level.

The significant risks on the Trust Risk Register as at the 31 st March 2015 are outlined on page 15. Further details in respect of the Trust’s key risks, including significant clinical risks are outlined within the Trust’s Annual Quality Statement (AQS). The AQS is included within the Trust Annual Report which is held on the Trust Internet site under key publications.

Standards for Health Services in Wales

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The Trust’s Assurance Framework is underpinned by the Doing Well, Doing Better: Standards for Health Services in Wales as its framework for gaining assurance on its ability to fulfil its aims and objectives for the delivery of safe, high quality health services. This involves self assessment of performance against the standards across all activities and at all levels throughout the organisation.

As part of this process, the Board has completed the Governance & Accountability assessment module and has;

openly assessed its performance using the maturity matrix; responded to feedback from Healthcare Inspectorate Wales in relation to its 2014-

2015 self assessment; plans in place to achieve the improvement actions identified within clearly defined

timescales proportionate to the risk.

This process has been subject to independent internal assurance by the organisation’s Head of Internal Audit. The internal audit review confirmed that a satisfactory process exists for the review and completion of the Governance and Accountability Module, involving Executives and, Independent Members. There were no recommendations received in respect of the completion of the Governance and Accountability module.

Velindre NHS Trust

Governance and Accountability

Module

do not yet have a clear, agreed

understanding of where they are

(or how they are doing) and what / where they need

to improve.

are aware of the improvements that need to be made and have

prioritised them, but are not yet

able to demonstrate meaningful

action.

are developing plans and

processes and can demonstrate

progress with some of their key

areas for improvement.

have well developed plans

and processes and can

demonstrate sustainable

improvement throughout the organisation /

business.

can demonstrate sustained good

practice and innovation that is

shared throughout the organisation/

business, and which others can

learn from.

Setting the Direction

Enabling Delivery

Delivering results achieving excellence

Overall Maturity Level

The Trust’s self assessment of the overall maturity level has remained the same for 2014/2015 as was assessed in 2013/2014. An action plan has been developed to address areas for continuous improvement for 2015/2016 which includes;

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Taking forward the activity outlined in the New Communications & Engagement Strategy to improve communications internally and externally, including an initiative to progress the use and management of social media.

Further strengthening the performance management arrangements within the Trust. Improving the process for mapping organisational learning within the Trust to ensure

clarity and consistency and understanding of the approach. Finailising the development of organisational Values in partnership with staff at all

levels of the Trust. Review Committee Independent Member membership to ensure succession

planning, knowledge and skill ‘churn’.

The audit of the Standards for Health Services in Wales conducted by Internal Audit concluded that there are robust processes in place within the Trust to ensure that the Standards for Health Services 2014-2015 Self Assessment was effectively completed in a timely manner and supported by appropriate narrative and scoring. The level of assurance given as to the effectiveness of the system of internal control in place to manage the risk associated with the processes in place for embedding, utilisation and self assessment of the Standards for Health Services in Wales is Substantial Assurance.

There were no high priority issues identified during the audit reviewNWSSP Shared Services Partnership Committee (SSPC) also undertook a self assessment of their position in relation to the Governance & Accountability assessment module and the outcome of this assessment is summarised in the table below. This process was subject to independent internal assurance by the organisation’s Head of Internal Audit.

NHS Wales Shared Services Partnership

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Governance and Accountability

Module

do not yet have a clear, agreed

understanding of where they are

(or how they are doing) and what / where they need

to improve.

are aware of the improvements that need to be made and have

prioritised them, but are not yet

able to demonstrate

meaningful action.

are developing plans and

processes and can demonstrate progress with

some of their key areas for

improvement.

have well developed plans

and processes and can

demonstrate sustainable

improvement throughout the organisation /

business.

can demonstrate sustained good

practice and innovation that is

shared throughout the organisation/ business, and

which others can learn from.

Setting the Direction

Enabling Delivery

Delivering results achieving excellence

Overall Maturity Level

The NWSSP’s self assessment of the overall maturity level has remained the same for 2014/2015 as was assessed in 2013/2014. An action plan has been developed to address areas for continuous improvement for 2015/2016 which includes;

Finalise and cascade the Communications and Engagement Strategy detail in summary to relevant staff.

Produce a protocol on Records Management for NWSSP to support the Velindre NHS Trust Policy.

Undertake the Caldicott Assessment for 2015-16. Ensure all Directorate Risk Registers are entered onto Datix Risk Management

software. Develop stronger links with universities and colleges to support the recruitment of

professional staff. Instigate phase 2 of the new induction toolkit. Further develop Performance, Appraisal, Development and Review (PADR) content

to link more closely with organisational objectives.

1000 Lives Plus Activity

Velindre NHS Trust has embraced the 1000 Lives Plus Campaign over the last few years with particular focus on the work within the Velindre Cancer Centre. The Cancer Centre continues to lead on developing the harm and mortality tools adapted for use within an oncology setting. Excellent results have been achieved in many of the work streams

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including the treatment of acutely ill patients, improving mouth care, Carer’s Strategy (Wales) Measure and ‘Ask about Clots Campaign’.Work is progressing on educating staff with quality improvement skills which has been incorporated into the Velindre Improvement Programme (VIP).

Further information in respect of the Trusts 1000 Lives Plus activity is included within the Trust’s Annual Quality Statement.

Review of Effectiveness

As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the system of internal control is informed by the work of the internal auditors, and the Executive officers within the organisation who have responsibility for the development and maintenance of the internal control framework, and comments made by external auditors in their audit letter and other reports.

My performance in the discharge of these personal responsibilities is assessed by the Director General of the Department of Health & Social Services /Chief Executive of NHS Wales.

My review of the effectiveness of the system of internal control is informed by the work of Internal and External Auditors, the Executive Directors and other assessment and assurance reports including the work of Healthcare Inspectorate Wales. I have listened to the Board on their views on the strengths and opportunities in the system of internal control and been advised by the work of the Audit Committee and other Committees established by the Board.

The scrutiny of these arrangements is in part informed through the internal mechanisms already referred to, but also through the independent and impartial views expressed by a range of bodies external to the Trust, where during 2014-2015 no significant issues have been identified. These include;

Welsh Government Wales Audit Office Internal Audit (NHS Wales Shared Services) Healthcare Inspectorate Wales Welsh Risk Pool Services Community Health Councils Health & Safety Executive Other accredited bodies

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Internal Audit Opinion & Scores for 2014-2015

Internal audit provide me and the Board through the Audit Committee with a flow of assurance on the system of internal control. I have commissioned a programme of audit work which has been delivered in accordance with public sector internal audit standards by the NHS Wales Shared Services Partnership. The scope of this work is agreed with the Audit Committee and is focussed on significant risk areas and local improvement priorities.

The overall opinion by the Head of Internal Audit on governance, risk management and control is a function of this risk based audit programme and contributes to the picture of assurance available to the Board in reviewing effectiveness and supporting our drive for continuous improvement.

The Head of Internal Audit (HIA)

The scope of opinion is confined to those areas examined in the risk based audit plan which has been agreed with senior management and approved by the Audit Committee. The HIA assessment should be interpreted in this context when reviewing the effectiveness of the system of internal control and be seen as internal driver for continuous improvement. The HIA opinion on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management, and control is set out below.

In reaching this opinion the HIA identified that the majority of reviews during the year concluded positively with robust control arrangements operating in some areas with all the main reviews receiving reasonable or substantial assurance.

The Trust commissioned Internal Auditors to undertake work to review the Welsh Blood Service Dafen project, where a number of control weakness were subsequently identified. The Trust responded to all audit recommendations by compiling and delivering a comprehensive action plan which was closely monitored by the Trust’s Executive

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Reas

onab

leas

sura

nce

- +Yellow

The Trust Board can take reasonable assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. Some matters require management attention in control design or compliance with low to moderate impact on residual risk exposure until resolved.

Management Board and Audit Committee. The lessons learnt have been acted on at an individual and organisational level. The senior management at Welsh Blood Service and the Trust have confidence that sound risk management, control and governance, access to expert advice and other business systems are now in place to ensure there is no reoccurrence.

Wales Audit Office Structured Assessment 2014

The Trust’s External Auditors (Wales Audit Office) conducted a Structured Assessment during 2014 that focussed on the corporate arrangements for ensuring that resources are used efficiently, effectively and economically.

The Wales Audit Office (WAO) Structured Assessment 2014, found that;

Part 1: Sound financial management ensures the Trust breaks even but some specific financial challenges within Velindre Cancer Centre (VCC) still need to be addressed.

Part 2: Governance arrangements are effective and there is an agreed three year Integrated Medium Term Plan (IMTP). There are opportunities to improve the detail and co-ordination of the information provided to Committees to support scrutiny, challenge and oversight.

Part 3: The Trust is strengthening the way it manages and delivers larger scale change. While there is extra senior capacity, further changes are needed in key resource areas to support delivery of the IMTP.

A limited number of recommendations are being addressed by the Executive Management Board and progress will be monitored by the Audit Committee by scrutiny of the Audit Action Plan.

Information Governance

The Trust has well established arrangements for Information Governance to ensure that information is managed in line with the relevant Information Governance law, regulations and Information Commissioner’s Office guidance. The arrangements include a Trust-wide Information Governance & IM&T Committee, Trust, Divisional and Hosted Organisation Caldicott Guardians, a Caldicott Guardian for the National Databases and Divisional Information Governance leads.

The statement on the quality of data reported to the Board is included within the Annual Quality Statement Velindre NHS Trust Annual Report. In summary, information is provided

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from our data management and quality improvement systems. To the best of our knowledge, this information is accurate and gives a true picture of the organisation.

Integrated Medium Term Plan

The achievement of the Trust’s vision and strategic objectives is driven by the Integrated Medium Term Plan (IMTP), which sets out the priorities and actions that will be delivered on a rolling 3 year basis. In March 2014, Velindre NHS Trust, in accordance with the set administrative duty, was one of four Local Health Boards and Trusts who had its IMTP approved by the Welsh Government. This followed revised national planning requirements in 2013 and a move from an annual to a three year planning process. Having an approved IMTP in place is a key way of demonstrating to the local population, Board, staff, partners and the Welsh Government that the organisation possess the requisite level of maturity to plan and deliver with confidence over a three year period. The IMTP will be refreshed on an annual basis, approved by Trust Board in March each year.

The Trust provided a reflection on progress against the key priorities, performance and ambitions outlined in the IMTP for 2014/2015 within the IMTP for 2015/2016, which was considered by the Planning & Performance Committee and Trust Board. This assessment was a high level overview of performance against the overall plan. This confirmed that delivery against activities was broadly in accordance with the forecast trajectory. The Trust will undertake a more in-depth review of achievements during 2015/2016 once all performance information has been validated. In respect of the financial performance the Trust reported a small surplus against its income and expenditure position for the year ended 31st March 2015, as reflected in the Annual Accounts. This review and reflection on the IMTP for 2014/2015 will be subject to scrutiny and assurance through the Planning and Performance Committee and Trust Board during July 2015.

The Trust submitted its’ Board approved IMTP for 2015/2016 in accordance with the NHS Planning Framework on the 1st April 2015. . The Minister wrote to the Trust on 2 June 2015 confirming approval of the Trust’s IMTP.

Ministerial Directions

A list of Ministerial Directions issued by the Welsh Government during 2014-15 are available at:- http://gov.wales/legislation/subordinate/nonsi/nhswales/2014/?lang=en Whilst Ministerial Directions are received by Local Health Boards, these are not always applicable to Velindre NHS Trust. All Ministerial Directions issued throughout the year are listed on the Welsh Governance website above. During 2014/15 six Non-Statutory

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Instruments were issued by the Welsh Government. Each of these were aimed specifically at services which are delivered by health boards, so no action was required by the Trust.

Welsh Health Circulars were reintroduced during 2014-2015. Welsh Health Circulars issued by Welsh Government are logged by the Trust Secretary and assigned an Executive Lead to assess the impact to the Trust and take forward necessary actions as appropriate. A register and action log is maintained by the Trust Secretary.

A list of Welsh Health Circulars issued by the Welsh Government during 2014-2015 are available at: - http://howis.wales.nhs.uk/whcirculars.cfm

Equality & Diversity

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The control measures include;

Trust Equality Monitoring Annual Report. Equality reports to Quality and Safety Committee on the Trusts Equality Objectives

and Actions Reports to the Equality and Human Rights Commissions’ enquiries. Reports to the Centre for Equality and Human Rights enquires. Report to the Welsh Government Equalities Team. Provision of evidence to the Health Care Standards Audit, specifically Standard 2. Equality Impact Assessments.

Disclosure Statements

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments in to the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.

I can confirm that the Trust has had no lapses in security data that have warranted reporting to the Information Commissioners Office in 2014-2015.

Whilst there is no requirement to comply with all elements of the UK Corporate Governance Code, Velindre NHS Trust has undertaken an assessment against the main principles as they relate to an NHS public sector organisation in Wales. This assessment has been informed by the Trust's assessment against the Governance

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and Accountability Module undertaken by the Board in April 2015 and also evidenced by internal and external audits. The Trust is clear that it is complying with the main principles of the Code, is following the spirit of the Code to good effect and is conducting its business openly and in line with the Code. The Board recognises that not all reporting elements of the Code are outlined in this Governance Statement but are reported more fully in the Trust's wider Annual Report.

The Trust’s Carbon Reduction Strategy was approved in September 2013. The organisation is undertaking risk assessments and carbon reduction delivery plans are being developed in accordance with emergency preparedness and civil contingency requirements as based on UK Climate Impact Programme (UKCIP) 2009 weather projections to ensure that the organisation’s obligation under the Climate Change Act and the Adaptation reporting requirements are fulfilled as detailed in the Welsh Government statutory guidance documents ‘Preparing for a changing climate Part 1 and part 2.

Conclusion

I can confirm that no significant internal control or governance issues have been identified in this statement.

Signed by Mr Steve HamInterim Chief Executive:

Date: 5th June 2015

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Velindre NHS Trust

Annual Quality Statement

2014/15

Darparu ansawdd, gofal a rhagoriaeth

Delivering quality, care & excellence

Introduction: Our Annual Quality Statement

Welcome to our Annual Quality Statement for 2014-15.

Velindre NHS Trust (or ‘the Trust’) provides specialist services to the people of Wales. We are made up of Velindre Cancer Centre and the Welsh Blood Service, as well as other organisations that we host on behalf of NHS Wales.

At Velindre Cancer Centre (VCC) we provide specialist non surgical cancer treatments to people living in South East Wales. Most of our

services are provided at the Velindre Cancer Centre in Whitchurch, Cardiff, but we also hold some clinics and services in other hospitals across Cardiff and Vale, Gwent, Rhondda Cynon Taff and Bridgend.

Through the Welsh Blood Service (WBS) we collect blood donations in South, West and parts of Mid Wales. The Welsh Blood Service also operates the Welsh Bone Marrow Donor Registry.

Our intention is to always improve our services, and we are committed to providing safe, effective and high quality care and services that meet the needs and expectations of our patients, donors, and the wider public. We are proud of the services we provide and in this document we aim to share with you:

Information about the services we provide; What we are doing well and what we could do even better; and How we plan to improve in 2015/16.

We hope you find our Annual Quality Statement interesting and informative, and as in previous years we would be very interested in your feedback.

Professor Rosemary Kennedy Mr Steve Ham Chair Interim Chief Executive

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How Did We Do in 2014/15

Summary of our key achievements in 2014/15

Welsh Blood Service Velindre Cancer Centre

We achieved good performance in blood and transplant services.

Our plans for an All Wales Blood Service have been approved.

We retained all our operating licenses.

We have done a lot of work to ensure we are prepared for accreditation with the United Kingdom Accreditation Service (UKAS) which is required from 2016 onwards.

Introduced new equipment (blood grouping analysers) one month ahead of schedule.

We delivered very good performance against waiting times for cancer treatments

We treated the first metastatic brain patient in Wales using Stereotactic Radiotherapy treatment on a new specialised linear accelerator (radiotherapy treatment machine)

We have piloted an electronic Health Needs assessment (e-hna)

We Improved the environment on the First Floor ward to improve privacy and dignity for patients

We commenced treatment of gynaecology patients across South Wales with a new form of Image Guided Brachytherapy Treatment (IGBT) which will lead to improved outcomes

We redesigned the radiotherapy pathway for patients with Head and Neck and neurological cancers, reducing waiting times from 28 to 14/16 days respectively

Thanks to our fundraising team and the fantastic efforts of our supporters we have installed free Wi-Fi access across Velindre Velindre Cancer Centre

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Summary of our key challenges in 2014/15:

Welsh Blood Service Velindre Cancer Centre

Ensuring we were ready to launch a new Blood Establishment Computer System (BECS). BECS was successfully introduced in May 2015. It will be easier, better and safer than the old system.

Making detailed plans and engaging with staff and the public to ensure we are able to make the All Wales Blood Service a reality in 2016.

Developing a new Platelet Strategy to make sure our production processes conform to updated professional guidance. This will result in changes to our apheresis platelet collection clinics, and to our laboratory processes in the coming year.

Getting ready for the Welsh Transplantation and Immunogenetics Laboratory (WTaIL) histocompatability and immunogenetics modules of the All Wales laboratory Information Management System (LIMS).

Meeting the demand for treatment at times of increasing complexity of treatments in both radiotherapy & chemotherapy

Continued implementation of new and improved treatments at times of capacity and financial constraints

Financially challenging times within the NHS and public sector as a whole

Acute lack of accommodation on the Velindre site for patient and staff areas

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What we learnt from our Regulators and external reviewers in 2014/15

Services provided by the NHS in Wales are regulated, reviewed and monitored by a number of organisations to ensure standards are met. In this section we will tell you about feedback and learning we have received from:

The Community Health Council (CHC) The Good Manufacturing Practice audit Clinical Pathology Accreditation (CPA) The ‘Trusted to Care’ review Spot checks

Community Health CouncilThe Community Health Council (CHC) has a statutory duty to represent the interests of people using health services. The CHC visited the Chemotherapy Inpatient Ward in the Velindre Cancer Centre during January 2015 and spoke to patients, carers and staff on duty. The CHC provided very positive feedback and commented on the high standard of care and treatment provided on the ward. They did however ask us to see if we could arrange for volunteers to provide a newspaper trolley service during weekends and we hope to be able to put this in place soon.

Good Manufacturing Practice (GMP)In October 2014 we received feedback from a ‘good manufacturing practice’ (GMP) audit of our aseptic pharmacy services in the Velindre Cancer Centre. The audit involved assessment of 179 standards and is based on the medicines Healthcare Products Regulatory Agency (MHRA) audit for licensed units in the UK; 137 standards were found to be satisfactory and 42 required improvement. We have developed an action plan to address all of the issues identified. We aim to complete all of the improvement actions by June 2015.

Clinical Pathology Accreditation (CPA)The Welsh Blood Service retained its Clinical Pathology Accreditation (CPA) for diagnostics laboratories following an inspection early in 2015. In the future Clinical Pathology Accreditation (CPA) will be replaced by UK Accreditation Services (UKAS) who will inspect the Welsh Blood service laboratories under ISO 15189 and ISO 17043.

Learning lessons from the ‘Trusted to Care’ review

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Following publication of the ‘Trusted to Care’ report we did a self assessment to check that the services we provide to frail older people are of the required standard. We shared our findings with the Minister for Health and Social Services in Wales, and also the Commissioner for Older People in Wales. As part of this work we reviewed how we manage medicines in the Velindre Cancer Centre and reviewed our policies and procedures to further improve this. In 2015/16 we plan to work with colleagues in the University of South Wales to review the impact these changes have had on patients and nurses.

‘Spot Checks’During 2014 the Welsh Government undertook unannounced ‘spot check’ visits to every district general hospital in Wales. The Velindre Cancer Centre was visited on the 15 th June 2014. The feedback we had was very positive overall although we were told that the door of one of our treatment rooms was propped open because the room was too hot. We took immediate action to address this and also checked the temperature in all of the rooms in which we store medicines. The spot check team also identified examples of good practice at the Velindre Cancer Centre which they felt would benefit other hospital sites, including the way that continence needs are monitored, and how privacy and dignity is supported.

Promoting Health

Across Velindre NHS Trust we aspire to ‘Make Every Contact Count’. This means that we try to find ways of providing advice to help improve the general health and wellbeing of our patients, donors and staff. Later in this statement we will tell you about some of the specific work we do to support people to ‘live well’ with cancer, but below are some examples of our wider work in promoting health and wellbeing.

Health and wellbeing of staffIn September 2014 we appointed a Health and Wellbeing Facilitator to take forward health and wellbeing initiatives for staff. Initial work focused on better understanding how we support staff and how this might be different in the future. In 2015 we will be launching a health and wellbeing strategy, and will also set up a health and wellbeing forum for staff to help them self manage conditions including stress, musclo-skeletal conditions, diet and nutrition, and physical exercise. We believe that if we support and help staff to look after their own health and wellbeing that they will be better able to support patients, carers and donors.

Vaccination

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In 2014/15 we promoted flu vaccination amongst our staff. The Welsh Government target was 50% staff uptake, and we were pleased that 69% of our staff took up the offer of vaccination. In 2013/14 56% of our staff were vaccinated. In 2015 we will continue to encourage our staff and patients to be vaccinated, and we will issue a short survey to better understand the reasons why some staff would prefer not to.

International Health LinksIn May 2014 the Welsh Blood Service (WBS) donated a blood collection vehicle to The National Blood Transfusion Services of Ghana (NBSG). Over the years, the blood collection vehicle has visited many locations and has collected 1000’s of units of blood from donors in Wales. Staff at the Welsh Blood Service in Talbot Green gave a fond farewell to the old vehicle as it headed on its journey to Ghana to help save even more lives.

Justina Ansah, Director of the National Blood Service Ghana said:

“Easy accessibility to blood donation sites offers an opportunity for eligible prospective donors of the general public to translate public awareness into practice. The donation of the blood mobile trailer therefore will help immensely with the public’s response to voluntary blood donation, especially as Ghana is restructuring and modernizing and at the same time grappling with attaining 100% voluntary donation. The blood mobile will definitely add extra versatility to the blood collection programme. On behalf of the Ministry of Health Ghana, the NBSG and recipients of blood and blood components in Ghana I extend our sincerest appreciation for the kind donation from WBS.”

Providing Safe Care

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In 2014/15 our goal was to keep patients and donors safe by avoiding harm from care and treatment that was intended to help. In this section we will tell you about our work in relation to:

Infection prevention and control Cleanliness Learning from serious incidents Preventing falls; Avoiding pressure ulcers

Infection Prevention and Control We know that patients who attend Velindre Cancer Centre often have a weakened immune system. Therefore we have a ‘zero tolerance’ approach to infections being picked up in our hospital. We support our staff to do this by adopting national guidance and standards. For example, we know that some treatments have a greater risk of infection than others, including when we use catheters as part of a treatment plan. To reduce the risk of this type of infection we only use such devices when absolutely necessary. During 2014/15 we achieved a 22% reduction in the number of catheters used for female patients, and a 50% reduction in male patients.

We know that hand washing is a simple and effective way of reducing the spread of infection. We encourage patients to ask staff about hand hygiene practices and every month we ask about this in our patient experience survey. In May 2014 we asked 40 patients if they had seen staff clean their hands before they cared for them:

In 2014/15 we have:

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C.diff Reduced the number of Clostridium difficile (sometimes called C. difficile or C.diff) infections:

o 8 cases in 2014/15o 14 cases in 2013/14o 13 cases in 2012/13

MRSA Reduced the number of Meticillin Resistant Staphylococcus aureus (MRSA) blood stream infections:

o 0 cases in 2014/15o 2 cases in 2013/14o 0 cases in 2012/13

MSSA Reduced the rates of Meticillin Sensitive Staphylococcus aureus (MSSA) blood stream infections:

o 2 cases in 2014/15, o 7 cases in 2013/14o 7 cases in 2012/13

CleanlinessEnsuring a clean environment is essential when preventing and controlling the spread of infections.

In our 2012/13 Annual Quality Statement we reported scores of over 90% in our All Wales Credit for Cleaning Standards audit. Our scores for 2013/14 and 2014/15 are provided below:

Type of Area Target Score (%) 2013/14 Score (%) 2014/15 Score (%)Very High Risk Areas

98 100 96*

High Risk Areas 95 95 94Significant Risk Areas

85 91 94

Low Risk Areas 75 86 89

*In 2014/15 the ‘Very High Risk Areas’ percentage score decreased as a result of the condition of the building in our theatre, not through any cleanliness issues. Currently there is a business case near completion to redevelop of the theatre location and therefore the building issues will be addressed within this scheme.

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We also ask representatives of our Patient Liaison Group (PLG) to do an independent audit using the Credit for Cleaning audit tool. In 2012/13 we scored 93%. In 2013/14 we scored 97%. In 2014/15 a member of “Friends of Velindre Organisation” carried out the external audit and we achieved a score of 97%. We also asked patients about our Operational Services:

During 2012/13 During 2013/14 During 2014/15

96% were satisfied with Catering services

93% were satisfied with Portering services

93% were satisfied with Domestic services

96% were satisfied with Catering services

93% were satisfied with Portering services

94% were satisfied with Domestic services

92% were satisfied with Catering services*

95% were satisfied with Portering services

95% were satisfied with Domestic services

*In relation to the decrease in the ‘Catering services’ percentage score, for 2014/15 we added additional questions addressing the out of hours provision for catering. As a result it has affected our overall compliance rate. This has been highlighted and is being addressed at our In-patient Nutrition and Catering meeting at Velindre Cancer Centre.

We routinely asked patients for their views about cleanliness. Between April 2014 and February 2015 we asked 206 patients:

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Learning from serious incidentsThe Velindre Cancer Centre has a Significant Clinical Incident Forum (SCIF). In 2014/2015 the Significant Clinical Incident Forum (SCIF) investigated 44 clinical incidents to learn lessons about what went wrong. After each meeting key areas of learning are sent out to all clinical staff. Examples are shown below.

The Welsh Blood Service also investigate anything that could affect the safety and quality of donated blood, and to report this to the Medicines and Healthcare products Regulatory Agency (MHRA). During 2014/15, the Welsh Blood Service reported and reviewed 3 incidents related to blood collection. Actions to prevent recurrence were taken as necessary for example changes to standard operating procedures (SOP) and the provision of additional staff training.

Case Example:

During the donor screening process it was identified that a donor malaria antibody test (MAT) sample had not been triggered when the donor attended the clinic previously. A ‘look back’ investigation was done to ensure that there were no blood components in stock that could pose a risk if transfused.

Falls prevention We know that whilst anyone can have a fall, older people are more likely to fall than others. We also know that having a long-term health condition, poor vision, or muscle weakness increases the chances of someone falling. Falls sometimes result in injury and can also affect a person’s self confidence and independence.

Through making changes to practice and the care environment we have consistently been able to reduce the number of patients who fall during their inpatient stay as can been seen below.

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Avoiding pressure ulcers Pressure ulcers (sometimes called pressure sores or bed sores) develop when the blood supply to the skin is reduced by prolonged or severe pressure. This causes the skin to be starved of oxygen and nutrients and it starts to break down. They tend to affect:

people with health problems that make it difficult for them to move; people aged over 70; and People who are confined to bed or sit for long periods of time without moving.

In 2014/15 13 people developed a pressure ulcer whilst in the Velindre Cancer Centre.

We use the ‘skin care bundle’ to help us reduce the risk of someone developing a pressure ulcer. This involves:

Assessing every patient’s risk of developing pressure ulcers; Helping those at risk to change position in their bed or chair; and Using specially designed equipment, like mattresses, cushions and heel

protectors, to reduce the risk.

We check how well we are doing each month as can be seen from the chart below.

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Effective and Evidence Based Care

In 2014/15 our goal was to ensure that our services were based on current scientific knowledge and best practice. In this section we will tell you about our work in relation to:

Implementing Clinical Guidelines Auditing our clinical services Research and Development Learning from complaints and concerns

Implementing clinical guidelinesThe National Institute for Health and Clinical Excellence (NICE) provide health services and the public with information about effective and good value healthcare. In 2014/15 the Trust received 73 documents from NICE:

18 Clinical guidelines – guidelines about care for particular conditions 27 Technology appraisals – information about the effectiveness of

procedures and equipment 28 Interventional procedures – about whether treatments are effective and safe

enough for use in the NHS

We implemented guidance that was relevant to our services. An example of how this changed the way in which we work is included below:

In May 2014 NICE issued Quality Standard 56 about the management of Metastatic Spinal Cord Compression (MSCC). MSCC is when the spinal cord is compressed or squeezed by cancer that started in or has spread to the bones of the spine. We reviewed the Standard and as a result we:

Provided information about MSCC to all patients who could be affected

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Developed a pathway to give clear directions to our clinicians about when a MRI scan should be arranged and treatment plans agreed and started

Audit Clinical audit and process audit enable our staff to check if care and treatment reached the expected standard. National, local and professional audits are carried out. During 2014/15:

30 clinical audits were completed in the Velindre Cancer Centre 64 process audits were undertaken in the Welsh Blood Service

When an audit is completed, recommendations are made to improve services and/or practice. An example of a change following an audit in the Velindre Cancer Centre is shown below:

Before the audit patients prescribed Vinorelbine (a chemotherapy drug) routinely had a blood test after 7 or 8 days before treatment was continued. The audit questioned the need for the blood test and as a result the specialists involved changed their practice so that the day 7/8 blood test is no longer routinely required before prescription of Vinorelbine is continued.

Every two years the Welsh Blood Service undertakes “Where does blood go?” audits to help hospitals understand how blood is used. The findings are used to influence practice, for example, reducing inappropriate blood transfusions in the treatment of iron deficiency anaemia.

ResearchTaking part in Research and Development (R&D) enables the Trust to improve services. It also contributes to the health and wellbeing of individuals and the wider population. There have been a number of exciting developments within R&D during 2014/15:

We signed Memorandums of Understanding with Cardiff University to formalise our arrangements for collaborative working and joint activities.

Velindre Cancer Centre are leading the way in the prestigious NISCHR Cancer Research Centre. This is a £4.5M initiative funded by NISCHR Welsh Government that will bring together researchers to take forward important areas of research.

We celebrated 20 years of undertaking clinical trials at Velindre Cancer Centre. Originally involving 3 staff the Trials Unit now has 34 staff, and have enabled more than 9,700 patients to participate in research projects. One of our current trial patients, said:

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In 2015 we will launch our revised R&D strategy which focuses on using research to allow our patients to access the latest therapies and treatments and receive the best care on offer. We will continue to work closely with our research partners to further develop our research projects, and we will develop a Memorandum of Understanding with the University of South Wales to enable us to take forward work to support our Nurses and Therapists to develop research skills.

Learning from Complaints and Concerns We investigated all complaints and concerns we received in accordance with the NHS Concerns, Complaints and Redress Arrangements (Wales) Regulations 2011. The graph below shows the total number of complaints we received during 2014/15:

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‘I had reached the point in 2012 where I had received all he conventional treatments for my prostate cancer including hormone injections, radiotherapy and chemotherapy. New treatments for this disease are thin on the ground so I was delighted to be offered the chance to become a phase 1 trial patient at the new well-equipped trial facility at Velindre. At the centre you receive first-class treatment from all the staff and there is a sense that you are participating in the development of what may be the next approved treatment for your disease’.

We thoroughly investigated all complaints and shared our findings openly and honestly with patients, their families, donors and staff. Complaints received about Velindre Cancer Centre were often complex and related to more than one issue. Many of the concerns about the Welsh Blood Service were about blood clinic times and clinic capacity.

Often people who complained or raised concerns told us that they did not want what happened to them to happen to someone else. We recognised the importance of viewing each complaint as an opportunity to improve the services we provided and regularly reported themes and learning to our Organisational Learning Committee. During 2014/15 we:

Took part in a public listening event (with Cardiff and Vale University Health Board and the Welsh Ambulance Service NHS Trust) to discuss the experiences of local people who had made a complaint or expressed a concern about our services.

Worked with Welsh Government, Health Boards and NHS Trusts to consider the findings of a national review about how the NHS Wales handles complaints.

We held a week long campaign to raise awareness about our complaints process amongst patients, relatives and staff. We used this as an opportunity to share lessons learned from our complaint investigations with our staff.

Dignified and Individualised Care

In 2014/15 our goal was to always provide dignified, respectful and individualised care, and to listen and learn from what our patients told us about the services we provided.

In this section we will tell you about: Our Patient and Carer Dignity Group Using patient and donor feedback to influence change Fundamentals of care Supporting our most vulnerable patients and their carers Supporting people to live well with cancer Equality and diversity

Our Patient and Carer Dignity Group

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We have an established patient and carer dignity group. The group reviewed all dignity related incidents and concerns arising in the Velindre Cancer Centre during the year. In 2014/15 they:

Provided dignity awareness training that focused on how a response of ‘he/she is not my patient’ might feel for a family member asking about their loved one.

Trialled use of buzzers in our outpatient department to avoid calling patients names out over the public address system.

‘Dignity checked’ refurbishment plans for one of our wards. Purchased 3,000 headphones for use with TVs on our wards.

The work of the group is supported by Independent Trust Board member Mr. Ray Singh CBE. Mr Singh, commenting in the Dignity Newsletter in January 2015 said:

We also routinely asked patients and carers if they felt that people were polite, whether they felt listened to, and whether they were given enough privacy. Of the 222 patients who we asked:

Polite: Listened to: Enough privacy:

Using Patient and Donor Feedback to make changes

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‘It is indeed reassuring and humbling to be listening to different team leaders of their commitment and

dedication to ensure that the dignity of the patients and their loved ones is first and foremost. They do not allow complacency to have a "breeding" place

within their activities.’

Every month we also asked patients in the Velindre Cancer Centre and donors attending our blood donation clinics to rate their experience of our services. Our findings are shown below:

Fundamentals of Care The Velindre Cancer Centre also undertakes an annual Fundamentals of Care (FOC) audit. 5 sets of randomly chosen notes from each of our three wards and the outpatient department are audited by one of our senior nurses and a representative from the Patient Liaison Group. In 2014 we also included our chemotherapy day units in the audit for the first time. The FOC audit provides a snapshot view of services on a given day in the year. The findings of the 2014/15 audit are shown below.

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Although there has been concern about the validity of the results in small services like the Velindre Cancer Centre we believe that the findings give us valuable information to further improve the services we provide. For example, our Action Plan includes actions to improve our documentation to better capture the details of assessment, care and discharge planning arrangements.

Supporting our most vulnerable patients and their families In 2014/15:

We have developed easy read information leaflets and care pathways to better support people with learning disabilities.

Offered training to Age Connect Cardiff & Vale’s Cancer and Older Person’s Advocacy Service.

Our Chaplains offered religious ministry and spiritual care to patients, carers and staff, and ensured our multi-faith prayer room was equipped to meet the needs of people of all faiths and cultures.

We started a three month study to collect feedback from patients and their families following discharge from one of our wards. We will use what we learn to improve

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the information and aftercare arrangements we put in place for patients in the future.

Our dedicated children and family visiting room was used 231 times, and 57 memory boxes were issued to children and young people to provide a special place to store treasured items and memories following the loss of a loved relative.

Our Supportive Care Nurse co-facilitated two children’s bereavement groups at Ty George Thomas, and early in 2015 published an article about the bereavement group in ‘CRUSE Bereavement Care’. The work will also be presented at the launch of the Children and Young Peoples’ Bereavement Forum in May 2015.

Our Equality and Diversity Manager and Supportive Care Lead Nurse worked with a local artist to develop a series of children’s books designed to help parents with a cancer diagnosis to talk to their children about cancer and its treatments. Mark Drakeford AM, Minister for Health and Social Care, will help us launch the book in May 2015.

Supporting people to ‘live well’ with cancerDuring 2014/15:

Our Therapy, Clinical Psychology and Supportive Care teams worked together to establish a nationally recognised Integrated Person-centred Care Pathway (PCCP). The pathway helps patients to develop psychological resilience and self management skills.

We continued to offer specialised treatments like neurological rehabilitation, acupuncture, vocational rehabilitation, and complementary therapies such as reflexology.

Issued ‘Top Tips’ information leaflets designed to help people develop coping strategies to help manage some of the common difficulties of living with the impact of cancer. For example, how to cope with cancer related fatigue.

Ran group sessions including Anxiety and Fatigue Management, Eat Well, Macmillan Activity Promotion Programme, Mindfulness, and the Living with Uncertainty group. We are pleased that the National Palliative Care Network plan to introduce Living with Uncertainty Groups across all services. A patient who benefited from attending group sessions said:

Supporting people to use their language of choice

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‘The presentations were very good. The variety of speakers, digital visual charts as well as the information provided by the handouts and workbooks gave us a good insight into helping with fatigue management. I had no real expectations to begin with. Now I have a clear plan of what I must do to alleviate much of my sleep and fatigue problems. Discussing with other people in the group who have similar problems and realising that one is not really on one’s own was very helpful. A worthwhile course that I was fortunate to be given the opportunity to attend.’

Sometimes we care for patients and donors who speak a different language, or use sign language. We use the Wales Interpretations and Translation Service (WITS) to help us. We also have a Welsh Language Scheme which aims to provide bilingual services to patients and donors who wish to communicate in Welsh. To find out more, you can read our Welsh Language Monitoring Report for 2013/14 here: http://www.wales.nhs.uk/sitesplus/972/page/55129.

During 2014/15 we:

Established Coffi a Chlebran, a group for staff who are new to learning Welsh. In 2015/16 we will be running Welsh language ‘Meet and greet’ courses in partnership with Cardiff University. We also plan to run a more advanced 30 week part time Welsh language course for some of our staff starting in September 2015.

Included Welsh medium books and magazines (kindly donated by S4C and Urdd Gobaith Cymru) in our children and family visiting room.

Ysgol Melin Gruffydd (Whitchurch Welsh Medium Primary School) sang Christmas carols for patients attending the Velindre Cancer Centre outpatient department.

Distributed ‘Laith Gwaith’ Welsh language lanyards and badges to staff so that patients, donors and others can easily and quickly identify Welsh speaking staff.

Introduced a fully bilingual telephone system at the Welsh Blood Service.

Timely Care and Services

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In 2014/15 our goal was to provide equitable and timely access to our services

In this section we will tell you about:

Waiting times and access to services Collecting enough blood

Waiting times and access to servicesDuring the year we saw increased demand for radiotherapy and chemotherapy services provided in the Velindre Cancer Centre. Our staff are working hard to meet the increase in demand and we are exploring new ways of working to reduce waiting times and improve access to our services.

RadiotherapyAs can be seen in the chart below we achieved our target of seeing 100% of people referred for emergency radiotherapy within 2 days but we know that we didn’t always see people referred for radical and palliative radiotherapy as speedily as we would have liked to. Starting in April 2015 we are trying out different staffing models and extended opening hours to test if they make a difference to waiting times.

Chemotherapy

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As can be seen from the chart below we have mostly been able to start chemotherapy within the target time that we set for ourselves. We are always striving to continuously improve our services. For example we are currently reviewing our pharmacy services to see if a different way of working will help with the chemotherapy waiting times.

During 2014/15 we asked 222 people for their views about how long they had to wait for services. This is what patients told us:

Collecting Enough Blood

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Thanks to the amazing support from our loyal and dedicated donors throughout the year we always collected enough blood and platelets to meet the demand from hospitals in Wales.

In addition, throughout 2014/15 we exceeded our targets in providing:

Routine antenatal patient results within 3 working days. Hospitals with Anti-D and cQuantitation results within 5 working days. Red cell reference serology results within 2 working days.

Bone Marrow DonationsIn last year’s Annual Quality Statement we told you how pleased we were with the increasing number of people volunteering on the Bone Morrow register. We are pleased to say that during 2014/15 we continued to exceed the number of people we hoped to recruit.

Our Staff and Volunteers

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In 2014/15 our goal was to support our staff to excel.

In this section we will tell you about:

Nurse staffing levels Implementing the Improving Quality Together Framework (IQT) Volunteers and volunteering

Nurse and Blood Collection staffing levels We know that it is important to get our nurse staffing numbers and skill mix (the mix of registered nurses and health care support workers/blood collection assistants) right. During 2014/15:

The Welsh Blood Service trained additional staff in venepuncture skills.

Nurse staffing levels were monitored in the Velindre Cancer Centre. Staffing Boards were introduced to show the staffing levels on each ward on a daily basis. We also started to reshape our nursing service by developing new nursing roles.

Improving Quality Together Framework (IQT)

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‘Improving Quality Together’ (IQT) is a framework of core service improvement skills which has been developed for NHS Wales staff and its contractors. Further information about the IQT initiative can be accessed at www.iqt.wales.nhs.uk/home. At the end of March 2015 we had supported 358 staff across the Trust to complete IQT training.

In 2014/15 the Welsh Blood Service created a Service Improvement Team. In the coming year the Team will use the IQT principles to develop service improvement skills in the Welsh Blood Service workforce. The aim is for all Welsh Blood Service staff to have completed IQT bronze by the end of next year.

Staff who did IQT Silver training during 2014/15 took forward a number of important service improvement projects. Examples are included below:

Improving the radiotherapy pathway to enable palliative patients who require a 3D plan to be treated within the Royal College of Radiologist's target of 14 days from date of referral to radiotherapy.

Chemotherapy Booking Centre: Improving the day to day throughput of patients. Lessons Learned in DATIX (DATIX is an electronic database where we store

information about incidents and concerns). Identifying and providing information to carers during in-patient admission Implementation of a ward-based discharge service Reducing noise levels on the wards at night Why don’t patients leave the Macmillan Cancer Unit with all the correct Take Home

Tablets they need? Increase the number of world faith in-patient referrals to the chaplaincy department

to be more reflective of local demographics Improving phlebotomy waiting times Improving communication with patients about waiting and clinic delays Network contingency for prescribing and dispensing in the Velindre Cancer Centre Improving quality of care for patients through more effective WBS (NEQAS) quality

assessment of transplant laboratories. We are very proud of our staff and their achievements. Details of people who have received recognition and reward for their work during 2014/15 are included elsewhere in our Annual Report.

The contribution of volunteers and volunteering

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The support provided by volunteers in the Velindre Cancer Centre and the Welsh Blood Service was widely recognised and valued throughout 2014/15.

Over 50 volunteers provided more than 14,000 hours of volunteering support to the Velindre Cancer Centre. A volunteer told us

Our Patient Liaison Group continued to support us by providing a patient view on a variety of issues and at out Trust Board.

Many volunteers continued to give their time to help raise funds for the Velindre Cancer Centre through our registered charity ‘Velindre Fundraising’. More information on this can be found on page 20 of our Annual Report.

During the year the Velindre Cancer Centre recognised the particular commitment from:o 2 people who had volunteered for 20 yearso 1 person who had volunteered for 15 yearso 1 person who had volunteered for 10 yearso 2 people who had volunteered for 5 years

In July 2014 the Welsh Blood Service reached a significant milestone of 900 blood stem cell donations, supporting patients in 30 different countries around the world.

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‘I love volunteering for Velindre. They make me feel valued and useful and I know I am doing

something worthwhile.’

The Welsh Blood Service has continued to benefit from new donors coming forward every month:

The Welsh Blood Service hosted donor award events to recognise blood, platelet and bone marrow donors who have reached milestone donations.

Looking Forward to 2015/16

Looking forward

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For detailed information about our service delivery plans for the future please refer to our three year plan for 2014/17 at:

http://www.wales.nhs.uk/sitesplus/documents/972/Velindre%20NHS%20Trust%203%20year%20plan%2031%20March%20%202014.pdf

This plan will provide you with information about what we intend to do and by when. It also identifies any factors that could influence our success.

Our three year plan sets out our detailed plans in relation to:

Providing fair and timely access to our services Supporting our staff to excel Providing care and research that is effective Ensuring safe and reliable services Delivering first class experiences for our patients Spending every pound wisely

Endorsement

Cardiff & Vale of Glamorgan The Local Patients NHS

“Watchdog”

During the past year we have undertaken the following activity relating to the Velindre NHS Trust and in particular the Cancer Centre.

Inspections

2 Inspections to the Cancer Centre Including the Outpatients Department and Chemotherapy Inpatient Ward

1 Hospital Patient Environment Audit we identified issues with the provision of hearing loops throughout the Cancer Centre.

1 Follow up Patient Environment Audit. We were pleased to note that following the issues relating to the provision of hearing loops Velindre purchased new units we are awaiting the results of a further audit as to the roll out of these across the Cancer Centre.

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The CHC continues to have constructive relationships with the Velindre NHS Trust through attendance at their Board Meetings and conversely at the CHC Council Meetings. We are currently working with Velindre on their performance reporting to make them more accessible to the public.

The CHC has provided some feedback into this year’s Annual Quality Statement and are confident the information provided is an honest appraisal of the services it provides. The CHC has endorsed the Annual Quality Statement for 2014-15. The CHC annual report for 2014/15 can be found on our website.

Lesley Jones Stephen AllenChair Chief Officer

www.communityhealthcouncils.org.uk/cardiffandvale

Further Information and Giving FeedbackIf you require further information about anything contained in this Annual Quality Statement, or would like to give us your feedback to help us improve the information we provide next year, please send an email to Corporate.Services2@wales.nhs.uk or write to us at:

Velindre NHS TrustCorporate HQ Unit 2 Charnwood Court Parc NantgarwCardiff, CF15 7QZ.

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Velindre NHS Trust

Statutory Compliance

Report

2014/15

Darparu ansawdd, gofal a rhagoriaeth

Delivering quality, care & excellence

Statutory Compliance

In addition to the need to report against the delivery against Standards for Health, the Trust is also required to report that arrangements are in place to manage and respond to the following governance issues:

Public Interest DeclarationEach Director has stated in writing that there is no relevant audit information of which the NHS body’s auditors are unaware. They have taken all the steps that they ought to have taken as a director in order to make them aware of any relevant audit information and to establish that the NHS body's auditors are aware of that information.

All Board members and Senior Managers within the Trust (including Directors of all Hosted Organisations) have declared any interests in companies which may result in a conflict with their managerial responsibilities. No material interests have been declared during 2014-2015.

Emergency Preparedness and Civil ContingenciesThe Trust has processes in place to ensure an appropriate response to a major incident in the local area. These plans are commensurate with the level of risk the Trust is exposed to. The ever changing environment of risk results in the strategies and plans being under constant review. Emerging threats are considered in the development and enhancement of risk mitigation strategies and the organisations response mechanisms.

The Trust is working towards enhancing the emergency planning process across all service areas and where appropriate it has systems and processes in place that demonstrate compliance with Welsh Government guidance and where necessary works with multi agency partners to improve resilience and plans have been tested in the last 12 months.

Strategic PlanningPatients, donors, carers and their families are at the centre of everything we do and their needs can only be met if we are able to create an environment which supports our staff in achieving their potential. In March Velindre NHS Trust submitted a three-year strategic plan to Welsh Government in accordance with the NHS Finance (Wales) Act 2014 and associated NHS Wales Planning Framework, which signalled a new medium-term approach to planning.

The plan (called “Delivering Excellence: Our Three Year Plan 2014/15 -2016/17”), which has been approved by the Minister for Health and Social Services , sets out how we will use resources over a three year period to:

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address the health needs of population areas and improve health outcomes; improve the quality of care; and ensure best value from resources.

This document sets out our plan for the next three years. It is intended to tell a clear and uncomplicated story about our priorities, the actions we wish to take, and the improvements and benefits we expect to see for patients, donors, carers, families, our staff and our partners.

Click here to view the plan: www.wales.nhs.uk/sitesplus/documents/972/Velindre%20NHS%20Trust%203%20year%20plan%2031%20March%20%202014.pdf

Progress with delivering an affordable workforce modelIn 2014/15 we have worked towards delivering an affordable workforce. We have a job vacancy scrutiny processes to ensure opportunities to work differently and more efficiently are explored. Our Voluntary Early Release (VERS) scheme has also been promoted, which was utilised by some members of staff who were eligible.

Staff Involvement The Trust has a Local Partnership Forum, attended by all Trust Executive and Service Directors and Trade Union Representatives, in addition to Local Consultative groups. Trade union representatives and staff have a presence on all significant Trust committees and groups and are involved in all aspects of service change.

Sickness Absence Data 2014/15Over the course of 2014/15 the sickness absence across the Trust has seen an increase of 2%. It is evident that there has been an increase in long term sickness throughout 2014 and a decrease in short term sickness.

As the data shows a slight increase, the Trust therefore has not achieved the Welsh Government Sickness Absence Rate of 3.54%. In order to address this, the Trust was successful with an Invest to Save bid in obtaining funding to create a new role of ‘Health & Wellbeing Facilitator’ and the post holder commenced in September 2014. The key objective for this post has been to concentrate on closely supporting and coaching Managers across all three divisions in Velindre Cancer Centre, Welsh Blood Service and Trust HQ with the overarching aim to reduce the sickness absence. The Workforce department continue to provide all Managers with sickness data. Actions plans have been created with Managers to ensure there is a consistent and fair approach throughout the Trust and ensuring the All Wales Sickness Policy is applied in relation to trigger points.

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In conjunction with addressing sickness absence management and as part of the Health & Wellbeing Facilitator objectives, new initiatives internal and external to the Trust have been researched. The proposed vision for the Trust is to provide all staff with access to help, advice and guidance that they may require to assist in looking after their own wellbeing. This will include initiatives such as a quarterly health and wellbeing forum which will cover particular health related topics, pulse surveys, promotion of the Occupational Health Service, Employee Assistance Programme and Complementary Therapies, as well as the promotion of Mindful Employer.

Staff Gender SplitThe table below shows the gender split of our staff (including Bank, Locum, Honorary, Retainer Scheme and Widow/Widower) on 31st March 2015:

Gender Headcount % FTE

Female 993 75.7 791.87

Male 319 24.3 291.01

Grand Total 1,312 100.0 1082.88

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Velindre NHS Trust Board Sickness Return 2014 - 2015

Trust Board Data Definition2014 / 2015 Data

Value Type Tab Found NOTE 2013 / 14 Variance %age Variance

Total Days Lost (Long Term):

28 days or more sickness, Absence Management Analysis, Long / Short Term Analysis

27,579.15 FTE Long Term % of sickness is long term

26,916.54 662.61 2.40

Total Days Lost (Short Term):

27 days or less sickness, Absence Management Analysis, Long / Short Term Analysis

12,882.39 FTE Short Term% of sickness is short term

12,807.69 74.70 0.58

Total Days Lost:

FTE Days Absent in the period. Absence Timeline Analysis. Cumulative FTE Days Absent

40,461.55 FTELong Term + Short Term

39,724.23 737.32 1.82

Total Staff Years Lost: (Average staff employed in the period – FTE)

SIP, FTE (Contracted) at end of each calendar month / 12 months (Apr – Mar)

2,895.15 FTE Staff in Post 2,882.58 12.57 0.43

Average Working Days Lost:

Based on 12 cumulative sickness absent rate use Calendar Days in a year - (52 Weekends + 30 Ave A/L + 8 BH)

8.5 DaysAve Wk Days Lost

8.4 0.1 1.18

Total Staff SIP, Headcount @ 3,285 Headcount Staff in Post 3,176 109 3.32

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Employed in Period (Headcount):

31 March 2014

Trust Board Data Definition2014 / 2015 Data

Value Type Tab Found NOTE 2013 / 14 Variance %age Variance

Total Staff Employed in Period with No Absence (Headcount):

Absence Timeline Analysis for the period by Employee Number, sort cumulative absence rate and count those with 0% absence.

1,623 Absence Timeline Analysis

1,484 139 8.56

Percentage Staff with No Sick Leave:

Staff with no sickness / Headcount SIP @ 31 Mar 2014

49.41% Absence Timeline Analysis

46.73% 2.68% 5.42

Sickness Absence Rate for Velindre NHS Trust 1 Apr 2014 - 31 Mar 2015

3.83%

Welsh Government Sickness Target for Velindre NHS Trust

3.54%

NHS Pension Scheme As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme Regulations are complied with. This includes ensuring that deductions from Salary, employer’s contributions and payments into the Scheme are in accordance with Scheme Rules and that member Pension Scheme Records are accurately updated in accordance with the timescales detailed in the Regulations.

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International Health Development

In 2014 Velindre NHS Trust became a signatory to the Charter for International Health Partnerships, launched by Welsh Government, making a public commitment to support global citizenship through effective partnerships and sustainable development goals.Velindre Cancer Centre and the Welsh Blood Service have a number of partnerships across Europe and Africa. One example of our work is outlined below:

Africa Links Project South Wales – Sierra Leone Cancer Care

The link was set up in 2010 with a Memorandum of Understanding in place between Velindre Cancer Centre (VCC) and the Ministry of Health and Sanitation (MoHS) in Sierra Leone. The link’s executive group has representation from across VCC and since 2010 has expanded to include professionals from Cardiff University, Abertawe Bro Morgannwg University Health Board (ABMuHB), Cardiff & Vale University Health Board (C&VuHB) and the Welsh Cancer Intelligence Surveillance Unit (WCISU). The link has five subgroups focusing on:

1. Cancer Registry2. Burkitt’s Lymphoma3. Palliative Care4. Education 5. Prevention of cancers

The multidisciplinary visit to Sierra Leone (led by VCC staff) in March 2014 led to an agreement of the project plan for 2014 – 15 with the Sierra Leone partners. This visit was funded by a grant (2013 -14) from the Wales Government Africa Links. A further grant was awarded to the link for 2014 – 15 by Welsh Government.

In April 2014 Ebola spread through Sierra Leone and remained a major health crisis throughout 2014 to April 2015 with 8,590 confirmed cases (http://health.gov.sl accessed 04.05.15) and an estimated 3,842 deaths in Sierra Leone from Ebola (WHO 15th April 2015). Sadly the most experienced doctor in one of the partner hospitals in Sierra Leona died from Ebola along with two nurses and a key person in the cancer registry data collection service fled the country.

Consequently many of the targets set for 2014 – 2015 have not been achievable. Throughout the Ebola crisis the link has been in regular contact with partners in Sierra Leone and two consignments of protective equipment have been donated.

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Cancer Registry

AchievementsThis is the first linked cancer registry in the World and was established by staff in VCC in partnership with other organisations and it is now formally recognised by the World Health Organisation (WHO).

Plans for 2014 – 15Following the March 2014 visit, approaches to widen data capture were agreed. The link aims to work with the Sierra Leone partners, WCISU and Cardiff University master degree students to expand capture to include clinical diagnosis and health care facilities throughout Freetown. A microscope with digital camera was donated to facilitate diagnosis and teaching. Ebola, however, led to restricted movement and increased pressure on staff resources within Sierra Leone, delaying implementation.

Burkitt’s lymphomaStaff from VCC,C&VuHB paediatric oncology team and ABMuHB paediatric team are working to help St John of God hospital, Lunsar develop a centre of excellence for the treatment of Burkitt’s Lymphoma, Burkitt’s Lymphoma is a paediatric cancer affecting an estimated 100 – 200 children each year in Sierra Leone. In the UK there is a 99% complete cure rate: a protocol used in 5 other African countries has shown a 60% complete cure rate. Previous visits have conducted needs assessments and agreement with the MoHS, Sierra Leone to develop a centre of treating Burkitt’s Lymphoma at St John of God hospital. Initial training of the staff was undertaken in 2013/14.

Key plans for 2014 – 15:Further teaching and the provision of equipment was planned for September 2014 to coincide with the opening of new laboratory facilities at the hospital. Placement of an oncology Specialist Registrar from VCC and a paediatric Specialist Registrar from ABMuHB, for a year to support the initiation of the project, was planned for Feb 2015. Funding was also awarded for an extra doctor at St John of God hospital to help set up the service. The treatment was to be complemented by the establishment of a mobile palliative care / symptom control team who would help ensure patients were able to return for follow up cycles of treatment and be monitored carefully throughout.

Achievements:During 2014 – 15 the link has been in collaboration with International experts and the authors of the Burkitt’s Lymphoma protocol used in other African countries and has refined the protocol to reflect the situation in Sierra Leone.

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Way Forward:The link has agreed that before this part of the project can progress, a further needs assessment, following the Ebola crisis, will need to be undertaken and a Memorandum of Understanding between St John of God hospital and VCC agreed.

EducationKey aspects of the project plan for 2014 – 15 were:

To work with the MoHS, Sierra Leone and College of Medicine and Health Science, University of Sierra Leone (COMAHS) to write culturally appropriate oncology and palliative care modules for the medical, pharmacy and nursing degree courses. These are in the process of being up-dated. The current undergraduate and post graduate courses do not include oncology or palliative care modules. The South Wales –Sierra Leone Cancer Care partnership was asked by the Dean of COMAHS to help teach / facilitate the teaching of these modules until Sierra Leone specialists were trained.

Provide a short course in the diagnosis, management and symptom control for the common cancers seen in Sierra Leone for qualified medical staff.

Facilitate a link between Cardiff University School of Healthcare Science and St John of God hospital school of Nursing to carry out joint projects. Initial projects were to focus on care linked to the treatment of Burkitt’s Lymphoma patients as part of the audit of the project.

Palliative CareThere is no formal palliative care training in Sierra Leone and only one centre providing palliative care. One key objective for 2014 – 15 was to provide further palliative training for all staff at St John of God hospital and facilitate a new mobile palliative care team. It is hoped this will be provided during 2015 -16.

Cancer Care in Connaught Hospital, FreetownThe Link is working with the diaspora charity, VIJI Cancer Care, to establish a ward within Connaught hospital (the main government hospital in Sierra Leone) for cancer patients and train nurses in the preparation and administration of chemotherapy, minimization of side effects and establish a palliative care team within the hospital. VIJI have raised the funds to equip the ward. The South Wales –Sierra Leone Cancer Care partnership were planning to train the medical staff in Sept 14, providing further support in subsequent visits and through teleconferences.

Key Objectives for 2015 - 16 Secure further funding when the Ebola crisis has subsided. Develop and deliver a module for oncology and palliative care specific to the needs

of Sierra Leone.

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Complete a further needs assessment for the treatment of Burkitt’s lymphoma and support St John of God hospital following the Ebola crisis.

Re-establish the cancer registry and strengthen the accrual of data following the Ebola crisis.

Renew the Memorandum of Understanding with the MoHS Sierra Leone and formalise a Memorandum of Understanding with St John of God hospital.

Work with St John of God hospital to establish a mobile palliative care team. Work with Connaught hospital and VIJI Cancer Care to train cancer care staff within

Connaught. Promote local engagement and awareness.

Members of the partnership acknowledge the benefits from being part of the project enhancing co-operation and insight into the role of other professionals, increasing experience in teaching, analysing work flow, enhancing problem solving and lateral thinking skills.

Following a study tour to Uganda in 2013, the Trust was successful this last year, in partnership with Public Health Wales, in securing a grant from the Wales for Africa fund for a follow-up visit to explore the country’s needs and priorities for nurse development. A small team of nurses visited the country in February 2015, hosted by the Ministry of Health in Uganda, and are currently considering opportunities for future collaborative partnerships.

Equality Diversity & Human RightsThe Equality & Human Rights Scheme 2011-2014, sets out how the Trust will meet its duties under the Equality Act 2010. The Scheme is an extension of the Trusts existing commitment to improve the lives of both its staff and service users and sets out actions to promote equality in health services.

The Trust aims to be a supportive place to work as well as ensuring that the services it provides does not in any way have a negative impact or discriminate against staff, patients, donors or visitors. To do this the Trust conducts Equality Impact Assessments (EQIA’s) on all its policies, procedures, guidance, business plans, schemes or proposed changes to services. This will ensure that any negative or indirect discrimination which could be an outcome of the policy etc is identified and risk assessed

The Trust is committed to equal opportunities and the elimination of unfair discrimination in employment. The Trust has an Equality & Diversity Policy which recognises and welcomes the benefits brought by a committed diverse workforce, which is broadly representative of the community it serves. This policy establishes the Trust’s approach towards equal opportunities and the key factors in ensuring that all staff and potential employees are treated fairly.

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To further promote Equality and Diversity, the Trust joined the Stonewall Diversity Champions programme and is now part of this good practice employers' forum on sexual orientation. Stonewall currently works with over 700 of the world’s leading organisations to create fully inclusive workplace environments by sharing best practice with its members. The tools available to members of the Diversity Champions programme and skills developed can be applied across any staff who fall within any of the protected characteristics and provide a platform by which the Trust can grow its visible commitment to Equality, Diversity and Human Rights. Through this membership the Trust strives to help make the workplace the best it can be for all staff, patients, donors, visitors and stakeholders by learning from others and clearly signaling the importance of an inclusive culture.

The Trust published its Equality Monitoring data Annual report in March 2015. The report contains analysis of employee data to look at the patterns and potential areas for development and support for staff, to ensure that the Trust has a workforce that is representative of the community to which it provides its services. An action plan supports the report, identifying ways in which to improve the data and meet our Equality duties under the Equality Act 2010. This action plan is then monitored via the Trust Quality and Safety Committee, Workforce and Organisational Development Group and at Board level.

In 2014 the Trust agreed a Flexible Working Policy recognising that Velindre NHS Trust requires a flexible workforce to deliver services and to recruit and retain staff. This policy also supports the Work and Families Act (2006); The Flexible Working Regulations (2002) and Employment Act (2002). Flexible Working is about challenging traditional full time working patterns and adjusting so that organisational needs are met and everyone, regarding of their diverse needs, can find a rhythm that enables them to combine work with their other responsibilities, changing situation and aspirations. This policy supports managers and staff to have constructive conversations to explore the different options available to ensure staff are able to contribute fully while also balancing any out of work responsibilities. All Trust policies are available online: http://www.wales.nhs.uk/sitesplus/972/page/55208

Velindre NHS Trust are partners of the Welsh Interpretation and Translation Service (WITS), further demonstrating the Trust’s commitment to addressing social and community issues. Through WITS we are able to cater for the needs of some of the hard-to-reach groups that we serve who do not use English or Welsh as their first language. The five top languages used were;

Czech Polish Slovak

Nepalese British Sign

Language

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Velindre NHS Trust is committed to helping our staff and the communities we serve to make appropriate lifestyle choices. We work with partner health organisations, such as Public Health Wales, to promote healthy living campaigns throughout the Trust and information stands for the public, offering a range of educational materials, were set up in public areas of our premises to raise awareness on subjects such as healthy eating, complimentary therapies, blood clots and sepsis.

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Sustainability

The Velindre Trust estate covers approximately 13 Hectares. It has a range of divisional premises including:

1 specialist Cancer hospital site at Whitchurch 3 Welsh Blood Service sites 1 Headquarters site land for future development

The four organisations hosted by Velindre NHS Trust have a wide range of properties and sites across Wales consisting of:

23 leased properties 1 freehold property

No direct services are provided to the public from these properties.

Work is continuing on the proposed new development of a cancer centre and potential outreach facilities. The case for change has been approved by Welsh Government and the Trust are working towards the next key stage review. In addition to this, facilities have been identified by the Welsh Blood Service in North Wales as part of the development of an All-Wales Blood service by 2016.

Velindre NHS Trust recognises that in our-day-to-day operations we impact upon the environment in a number of ways and therefore should report upon our potential impacts in a responsible manner. Sustainability reporting is an essential part of organisational governance in the public sector in Wales and the Welsh Government’s aim is to enable integrated reporting. For 2014/15 public bodies in Wales, which report under the FReM (Financial Reporting Manual) and meet the FReM de-minimis, are required to produce a FReM Sustainability Report.

In line with the reporting mechanism the Trust is committed to achieving continued improvement in the following areas;

Carbon Management Energy and Water Management Travel and Transport Waste Management Environmental Management System Climate Change Adaptation and Mitigation Sustainable Procurement Sustainable Construction

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Biodiversity and Natural Environment

Awareness Raising and Training

The environmental sustainability agenda is taken forward in a structured manner and supported by strong governance arrangements. The Director of Planning, Performance and Estates is the lead officer for environmental sustainability within the Trust. One of the Trust Board Independent Members is the Environment Champion and works closely with the Director of Planning, Performance and Estates and Trust Board to progress this important agenda. The Assistant Director of Estates, Environment and Capital Development and the Environmental Development and Compliance Officer, provide the Trust with additional capacity and capability to take forward the ambitious work programme. The planning and delivery arrangements related to sustainability within the Trust are set out below.

Performance 2014/2015The following tables, data and narrative set out the Trusts’ performance in sustainability for 2014/15 and compare it against previous years.

The Trust recognises the need to establish robust and accurate data to enable it to set realistic targets and manage data effectively. The Trust continues to make progress in this area but recognises there is more work to be done. The following data issues were identified whilst compiling this report:

Gas, water and waste data for leased buildings has been estimated due to no information being available as part of the lease agreement.

NWIS and NWSSP data has only been provided for business mileage data. This is due to data availability issues. The Trust recognises the need to report this information and has put transitional plans in place to ensure that the required information is provided within future reports.

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Trust Board

Lead Director / Independent Member Champion

Trust Sustainability

Divisional / Cancer Centre Quality and Safety Group

Divisional / Hosted Organisation Energy and Environmental

Planning and Performance Committee

Quality and Safety

The following data anomalies in previous report submissions are highlighted below, along with their rectifications:

Anomaly Reporting Period Rectification

1. Non Financial Indications, Gross Emissions Scope 1, 2 & 3.

2010/11

2011/12

2012/13

2013/14

Improved data availability and knowledge of report requirements (e.g. Scope 2 & 3 data had been included as Scope 1 previously prior to the reporting year 2012/13).

Improvements and modifications in data capture method and calculations relating to generator use and business mileage.

2. Related Energy Consumption, Other.

2010/11

2011/12

2012/13

Improvements and modifications in data capture method and calculations relating to generator use.

3. Financial Indicators, Expenditure Official Business Travel.

2010/11

2011/12

Improvements and modifications in data capture method and calculations relating to business mileage.

4. Non Financial Indicators, Water Consumption Office, Supplied.

2010/11

2011/12

2012/13

2013/14

Replacement of ‘estimated’ data with ‘actual’ data, received through billing, after the previous year’s report has been published.

Improvements and modifications in data capture method and calculations relating to water use.

Green House Gas Emissions 2010-11 2011-12 2012-13 2013-14 2014-15

Non Financial Total Gross Emissions

3.53 3.71 3.9 3.85 3.771,2,3

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Indicators (1,000 tCO2e)

Total Net Emissions

3.52 3.71 3.9 3.85 3.771,2,3

Gross Emissions Scope 1 (direct)

3.2 3.2 3.2 0.93 0.90

Gross Emission Scope 2 & 3 (indirect)

0.23 0.5 0.7 2.92 2.87

Related Energy Consumption (million kWh)

Electricity: Non Renewable

5.06 5.14 5.2 5.23 5.413

Electricity: Renewable

Nil Nil Nil Nil 0.000353

Gas 5.53 4.45 5.16 4.84 4.762,3

LPG Nil Nil Nil Nil NilOther 4.2 4.2 4.2 0.02 0.02

Financial Indicators (£million)

Expenditure on Energy

£0.64m £0.67m £0.69m £0.82m £0.83m2,3

CRC Licence Nil Nil Nil Nil NilExpenditure on Accredited Offsets e.g. GCOF

Nil Nil Nil Nil Nil

Expenditure on Official Business Travel

£0.25m £0.56m £0.77m £0.94m £0.79m4

1In the reporting of emissions the revised 2013/14 Defra grid average conversion factor has not been applied. This will be adopted in Wales in 2015/16. Emissions have been calculated using a consistent methodology to prior years, via 2013 Carbon Trust Conversion Factors.2For leased buildings with no information available on gas consumption, estimated figures have been used for both cost and consumption.4Business mileage figure includes NWIS and NWSSP (as per previous year’s submission).

Finite Resource; Water Consumption 2010-11 2011-12 2012-13 2013-14 2014-15 Non Financial Indicators (000m3)

Water Consumption (Office)

supplied 0.52 0.52 0.39 1.02 1.025

abstracted N/A N/A N/A N/A N/APer FTE N/A N/A N/A N/A N/A

Water Consumption (Non Office)

supplied 23.88 20.47 20.20 23.458 20.63abstracted

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

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Financial Indicators (£million)

Water supply costs (Office)

£0.002m £0.002m £0.001m £0.001m £0.001m5

Water supply costs (Non Office

£0.07m £0.05m £0.06m £0.032m £0.029m

5For leased buildings with no information available on water consumption, estimated figures have been used for both cost and consumption.

Waste 2010-11 2011-12 2012-13 2013-14 2014-15

Non Financial indicators (tonnes)

Total Waste 195 164.28 332.46 352.08 334.816

Landfill 125.6 96.15 135.5 162.40 145.586

Re-used/Recycled 28 30 94.3 73.01 116.966

Composted Nil Nil Nil Nil NilIncinerated with Energy Recovery

17.2 18.6 Nil 21.29 72.27

Incinerated without Energy Recovery

Nil Nil 71.66 95.38 Nil

Financial Indicators (£million)

Total Disposal Cost

£0.05m £0.05m £0.12m £0.13m £0.105m6

Landfill £0.02m £0.02m £0.05m £0.04m £0.026m6

Re-used/Recycled £0.004m £0.004m £0.01m £0.01m £0.038m6

Composted Nil Nil Nil Nil NilIncinerated with Energy Recovery

£0.01m £0.01m Nil £0.01m £0.041m

Incinerated without Energy Recovery

Nil Nil £0.05m £0.07m Nil

6For leased buildings with no information available on waste disposal, estimated figures have been used for both cost and tonnage.Carbon ManagementIn 2013 a Trust Carbon Reduction Strategy was developed in conjunction with the Carbon Trust. The implementation of the strategy will significantly reduce the carbon emissions created by the Trusts’ services over a five year period (2014 to 2019).

During 2014 Velindre NHS Trust entered into workshops with the Carbon Trust to look at “Behavioural Change” within the NHS. Following these workshops it set a potential outlook for a utility consumption saving of 10% over a five year period (2014 to 2019), based on a 2013/14 financial year baseline and in accordance with ‘Section 3: Targets & Business Case’

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of the Velindre NHS Trust Carbon Reduction Strategy. The following table identifies the annual percentage target reduction in electricity, gas and water consumptions and emissions and provides an explanation as to why each target has been set. This year’s performance target is highlighted in green.

Financial Year Percentage Target (%) Reason for Percentage Target

2014 - 2015 1%

This target was set in November 2014. It is a low percentage due to the target being set over half way through financial year 2014/15.

2015 - 2016 3%Energy awareness strategies and targets with suitable monitoring, being delivered by behavioural change.

2016 - 2017 3%Energy awareness strategies and targets with suitable monitoring, continual emphasis on behavioural change.

2017 - 2018 2%Investment required to maintain on-going savings.

2018 - 2019 1.5%Diminishing savings as investment required to further increase savings. Extra 0.5% to ensure 10% overall five year target is achieved.

Energy and Water Management During 2014/15 the Trust did not achieve its annual percentage target reduction in electricity consumption (non-renewable and renewable), showing an increase of 3.3 % compared with 2013/14. This was due to:

Increased operational hours of linacs and associated equipment at the Velindre Cancer Centre.

Lack of promotion and monitoring of energy awareness and education throughout the Trust.

Continued use of older, less energy efficient equipment such as linacs and refrigerators.

However, the Trust did achieve its annual percentage target reduction in gas and water consumption, showing a decrease of 1.7 % for gas and 11.5 % for water compared with 2013/14. This was achieved through:

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Continued monitoring and leak detection for water, particularly at the ‘non-office’ sites VCC and WBS.

Use of Building Management Systems (BMSs) to control heating controls throughout the year.

The Trust will continue to work towards achieving a significant reduction in its carbon emissions by focusing on the following:

Reducing electricity and gas consumptions through embedding ‘Don’t Waste at Work’ energy and waste campaigns and improving meter reading and data capture at all divisions / hosted organisations. Staff, patients and visitors all have a role to play in achieving these reductions.

Reviewing extended hours of use and use of equipment at divisions and ensuring this is taken into account in future year comparisons.

Upgrading Building Management Systems (BMSs) and replacement of inefficient boilers.

A pilot energy saving lighting scheme has been installed at Velindre Cancer Centre to reduce its operational impact on the environment. This scheme will be monitored and if the predicted reductions are achieved it could potentially be expanded across VCC as well as other sites.

Inefficient air-conditioning units have been replaced at the Welsh Blood Service in Talbot Green and Velindre Cancer Centre in Whitchurch. The BMS systems at each site will be re-configured to ensure energy efficiency is optimised.

Ensure that gas heating is switched off during the summer period or BMS controls are amended correctly to reflect summer temperatures.

Water and gas monitoring and leak detection good practice will continue over the next twelve months to ensure future targets are achieved.

Travel and TransportDuring 2014/15 the Trust expenditure and mileage on official business travel has decreased by 16 % and 20 % respectively compared with 2013/14. This is a result of the assumed following:

Increased use of public transport and car sharing for meeting and conference travel. Increased access to videoconferencing facilities at sites reducing the need to travel

to meetings. Amalgamation of a proportion of NWSSP offices into single office accommodation,

contributing to a reduction of inter-departmental travel.

The Trust will continue to work towards achieving a significant reduction in its carbon emissions by requesting that all staff, visitors and contractors consider the ‘Travel Hierarchy’ when arranging travel for commuting, meetings, conferences and visits. This includes:

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Videoconferencing facilities are available across Trust sites, allowing people at two or more locations to see and hear each other at the same time, minimising travel. Staff will be supported to make better use of these facilities to reduce unnecessary travel.

Walking is good for your heart, lungs, muscles, bones, joints, improves mood and boosts self-esteem. Many Trust sites are located within a short distance to green areas such as the Taff Trail. Staff will be supported to make better use of these facilities.

A ‘cycle to work’ scheme has been introduced at the Trust to make it easier for staff to purchase a bike. Secure bike shelters and showers are also available to encourage cycling to work. These options will be further promoted to staff to reduce unnecessary use of vehicles.

Bus and train services are included when directing staff, patients, donors, visitors and contractors to each division / hosted organisation, public transport must be made the first choice for staff conference travel.

Car sharing will be further encouraged, as well as using the journey for multiple purposes where possible (e.g. delivery of reports and board papers).

Travel options will be made available to all staff throughout the Trust through a site specific environmental awareness factsheet, with particular focus on staff that have not considered changing their travel habits before.

Waste Management The Welsh Government has set a target for all organisations to recycle at least 70 per cent of waste by 2025. Velindre NHS Trust has set an initial target for 2014/15 of 50 % recycling of its waste materials, as it moves towards the 70 % goal.

The Trust’s chosen clinical waste contractor is now recovering residual waste (flock) from clinical waste treatment plants. The contractor is also incinerating all non-flock remaining clinical waste with energy recovery. Therefore the Trust will now include any alternative treated and energy recovery incinerated clinical waste as recycled waste.

During 2014/15, the Trust achieved its annual recycling percentage target of 50 %, with a performance of 56.5 %. This was achieved through:

Inclusion of ‘alternative treated’ and ‘incinerated with energy recovery’ clinical waste as recycled waste.

Due to the contractor incinerating all non-flock remaining clinical waste with energy recovery, no clinical waste has been ‘incinerated without energy recovery’.

Introduction of the new ‘All-Wales NHS’ waste contract. Improved data collection procedure in line with Planning and Performance and

Integrated Quality and Performance Storyboard Trust Board reports.

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The Trust will continue to work towards increasing its recycling rate by focusing on a wide range of opportunities that include:

Continued implementation of the ‘All-Wales NHS’ waste contract and improved data collection procedure, whilst promoting and monitoring waste awareness and education across the Trust.

The Trust Environmental Development and Compliance Officer working with the Estates and Operational Services departments at all divisions to analyse the data capture of waste weights to ensure that the correct calculations are being used.

The waste disposal streams and processes will be analysed to ensure that they are correct and the right amount is disposed of as ‘recycled waste’.

Environmental Management SystemThe only hospital site that is part of the Velindre NHS Trust portfolio, the Velindre Cancer Centre, successfully maintained its ISO14001 accreditation in 2014/15. The hosted organisations, NWSSP and NWIS, have also successfully achieved ISO14001 for several of their sites. The percentage of the Trust’s properties that are certified to ISO14001 is currently 57 %, which is above the government target of 50 % by the end of 2015. The remaining divisions / hosted organisations are working towards achieving ISO14001 by the end of September 2015.

The benefits that have arised from EMS implementation include:

Improved environmental compliance Prevention of pollution Increased operational efficiency Cost savings Improved relations with regulatory agencies

Climate Change Adaptation and MitigationThe Trust has assessed the challenges and opportunities that more extreme weather conditions may bring, as outlined in the UK Climate Projections. These include:

More intense rainfall events. More flooding of low-lying coastal areas. Hotter, drier summers. More extremely warm days. Milder, wetter winters. Less snowfall and frost. Lower groundwater levels.

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The assessment is intended to assist organisations in developing robust plans to mitigate the potential impact and consequences of these risks. The Trust has introduced a Carbon Management Strategy which manages energy consumption across all divisions. Each division / hosted organisation has implemented or is in the process of implementing Business Continuity and Emergency Plans which signpost to all relevant procedures relating to evacuation, adverse weather and supplier / emergency services contacts. Moving forward, the above strategies and plans will be implemented and promoted further throughout the Trust.

Sustainable Procurement Velindre NHS Trust hosts Procurement Services, NHS Wales Shared Services Partnership (NWSSP), which provides procurement services to all health organisations, including Velindre NHS Trust. Procurement Services takes its responsibilities around Sustainability seriously. Their strategy is to source and deliver supply chain solutions for the NHS in Wales and where appropriate the wider Welsh public sector that offer a blended value of price, quality and sustainability to our stakeholders including patients, staff, supplier and the local community. For more details on the organisation please visit the website www.procurement.wales.nhs.uk.

Procurement Services identifies sustainability as one of the key objectives stating that their aim is: “To manage our Organisation and deliver outcomes that contributes to the Welsh Government Sustainable Development Agenda”

Through procuring via NWSSP, the Trust adheres to the NWSSP Corporate Social Responsibility (CSR) Policy. This splits activity around three key areas:

Sustainable procurement means purchasing goods and services in a way that maximises positive benefits and minimises negative impacts on society. Procuring from a mix of small, medium and large businesses and social enterprises can be considerable investment in the economy and community, contributing to regeneration and reducing health inequalities. Buying environmentally friendly products, such as less polluting cleaning products,

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biodegradable and energy efficient products, is less harmful to human and environmental health. Food procurement is important as healthy, nutritional and fresh food will contribute to improving the health and wellbeing of staff.

Sustainable Risk Assessments (SRA) are undertaken against each contract with an annual value of £25k+. SRAs are built into standard processes and procedures across the Trust. A flow chart of the process is detailed below showing the point at which the SRA is completed.

Working with Small, Medium Enterprises – The Trust endorses and works alongside NWSSP in their commitment to the Welsh Government’s ‘Opening Doors’ Charter for Small and Medium Enterprises (SMEs) that sets out an approach to improving engagement with SMEs. This takes the form of engaging with them at an early stage, attend meet the buyer/supplier events and considering our approach to the way in which we tender contracts in terms of geography. By NWSSP signing up to the Welsh Government’s ‘Opening Doors’ Charter, the Trust is committed to ensuring that SMEs in this area and in the rest of Wales are given the best opportunity to compete for our business.

Ethical Procurement - The Community Equipment Items Contract is a collaborative pan public sector Wales framework. The tender explored the extent to which bidders had undertaken ethical audits on their suppliers and a requirement for successful suppliers to work with us on developing this area. The new all Wales nurses and midwives uniform embedded the requirement for social and ethical compliance

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within its terms and conditions of contract across the whole supply chain i.e. fabric manufacture, dye house and garment manufacture.

Climate Change and Carbon Reduction – The Trust, through NWSSP, are working with suppliers to explore opportunities for them to reduce their carbon emissions. In respect of energy, contracts are in place for the supply of electricity and 100% of this supply is ‘green’ coming from a variety of renewable sources i.e. wind, solar and hydro power. In partnership with gas and electricity providers, recent contracts have negotiated the inclusion of automatic meter reading as a part of the contracts. This will help the Trust monitor and reduce energy consumption through improved management information and meter readings.

Sustainable ConstructionVelindre NHS Trust promotes sustainable design and construction and is committed to implementing sustainable development. The Trust recognises the need to take into account the resources used in construction, the environmental, social and economic impacts of the construction process itself and of how buildings are designed and used.

For major construction schemes in excess of £4 million, Velindre NHS Trust complies with the NHS in Wales’s construction procurement and delivery frameworks “The Designed for Life: Building for Wales”. The frameworks are based on the fundamental principles of collaborative working, integrated supply chains and continual improvement. Any future major new development will adhere to the above frameworks and all schemes will be designed and constructed to look to achieve the following:

Minimise the use of resources (including energy and water). Ensure that the built environment mitigates and is resilient to the impact of climate

change. Protect and enhance biodiversity and green infrastructure. Ensure the sustainable sourcing of materials. Ensure the sustainable sourcing of resources. Provide buildings and spaces that are pleasant and healthy for patients, staff and

visitors. Minimise waste.

As part of the Velindre NHS Trust commitment to environmental management we ensure that contractors adhere to our environmental rules:

Only connect to energy sources with division / hosted organisation agreement. Clean up any spillages of materials appropriately and notify the site contact to

ensure no substances enter into the drainage system. Ensure materials and expertise are appropriate for the activity.

Skips/waste containers must be secured and remove waste from site.Page | 106

Biodiversity and Natural Environment There is a growing understanding that there is significant interaction between wellbeing, health promotion and biodiversity. What is good for the climate and the environment is good for health. The Trust recognises the need to preserve and improve bio-diversity where possible within its existing boundaries and ensure that the Trust can potentially enhance the local biodiversity of the surrounding community. Significant improvements to the Trust divisions and hosted organisation sites have been made in relation to flora, with planting, hedge cutting and tree pruning completed in a sympathetic manner to support local wildlife, particularly at the Velindre Cancer Centre and Welsh Blood Centre.

The acquired land at Whitchurch, purchased for potential future development, comes with the opportunity for the Trust not only to maintain, where possible, the existing habitat but also provide a facility that will enhance the local habitat and environment as part of the design, construction and operational process. The aim will be to provide a sustainable facility that benefits patients, visitors, staff and the local community. To comply with the Trust’s sustainability agenda a biodiversity study will be undertaken on the proposed land for future development.

Awareness Raising and Training The Trust provides all new staff with environmental awareness training during their induction. Inductions are held every 4 to 6 weeks or more frequently if required. For all other staff environmental awareness training is provided as a mandatory training requirement currently every five years or when required. This training includes information on waste management, energy conservation, information on the Trust’s Environmental Management System and sustainable travel.

At present, there is a relatively low level of environmental awareness compliance, which has led to a review of training needs being undertaken. The Environmental Development & Compliance Officer is working with Education and Development to consider the following for the mandatory or statutory environmental training need:

Who needs to attend training? How often should training be repeated? How best to deliver the necessary training. Whether ‘foundation’ and ‘refresher’ training should differ (content, duration,

delivery methodology etc). Extending compliance across all divisions / hosted organisations of the Trust, not just

VCC, WBS and Velindre NHS Trust Headquarters.

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The outcome of this review has led to following being implemented over the next twelve months:

Amending the e-Learning package to include more waste management training for office based staff.

More specific and detailed training being given to staff that have a prominent role in minimising the environmental impacts at the Trust, including internal auditing, the management of waste and spillage training.

Every division / hosted organisation displaying their commitment to environmental management via notice boards and online web pages.

Principles of Remedy and Principles of Good AdministrationOn 14 March 2008, Adam Peat, Public Services Ombudsman for Wales issued statutory guidance to public bodies in Wales on Principles of Good Administration and Principles for Remedy. The principles were circulated widely across the Trust for consideration and implementation. The remedies include;

Getting it right Being customer focused Being open and accountable Acting fairly and apportionately Putting things right Seeking continuous improvement

The principles of remedy are incorporated into the Trust Concerns policy which was approved by the Board in 2012. All Concerns are investigated in line with the NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 and the Trust Being Open policy. Resources were strengthened during 2014/15 with the permanent appointment of a full time Concerns Manager. This new role has enabled the Trust to further embed the Putting Things Right Regulations and to develop processes to support the identification and sharing of lessons learned. In addition, the creation of a new post, Business Support Manager, within the Welsh Blood Service, with a lead role in concerns management, has enabled the division to develop and strengthen its concerns management practices.

The Trust is audited annually by the Welsh Risk Pool in relation to the “Concerns and Compensation Claims Standard”. The purpose of the audit is to ensure that all NHS Bodies have an effective process for managing concerns raised by patients and staff in accordance with the NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 which complements and supports the existing processes for the management of clinical negligence claims.

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The Trust has designated pages on its Internet and Intranet site to explain the process for raising a concern. See link: www.wales.nhs.uk/sitesplus/972/page/55236.

Research and Development (R&D)The delivery and management of high quality research is a strategic priority within Wales, and viewed by the Trust as the 2nd priority after clinical care. Research and development drives changes in healthcare, enabling us to translate innovation into practice and provides our patients with the best in care and quality, often allowing access to treatments that would otherwise not be possible.

There have been a number of exciting developments within R&D over the last 12 months that have strengthened our position as a leader in research within Wales. We have signed 2 Memorandums of understanding with Universities; the first, with Cardiff University, formalises the basis for collaborative working, aligning interests and themes and supports joint activities in key areas of interest (radiotherapy, stratified medicine and new drugs & treatments). The second is with the University of South Wales and supports our desire to support our Nurses and Allied Health Professionals to become researchers.

Velindre Cancer centre and staff are leading the way in the prestigious NISCHR Cancer Research Centre, a £4.5M initiative funded by NISCHR Welsh Government. This prestigious all Wales centre will bring together leaders from South West and North Wales, to perform and support research focussed on important areas of clinical need.

The Clinical Trials Unit celebrated 20 years of clinical trials at Velindre. The unit started in 194 wih 3 staff, since then the team has grown to 34 staff, and more than 9,700 patients have participated in research projects.

Velindre Research Labs continue to work on basic science projects that link into the Oncologists within the cancer Centre; for example the SKOPOS trial in mesothelioma is a collaboration with Dr Jason Lester, and the first clinical trial carried out at Velindre with a genetically modified vaccinia virus. Continuing on this theme of collaboration and excellence in care through research, there have been a number of key appointments:Dr Emiliano Spezi from the Medical Physics Department at Velindre Cancer Centre has recently been appointed to a Senior Lectureship in the Cardiff University School of Engineering’s Biomedical Engineering Research Group. Emiliano will divide his time equally between the University and Velindre where he will continue to develop his research activities in radiotherapy physics and related clinical trials.

Cardiff University and Velindre NHS Trust have jointly funded a Velindre Professor in Cancer Care which will be advertised in early summer 2015. The position will be held by a nurse or allied health professional.

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To help us elevate our ambitions and achievements in R&D, a new Assistant Director post was created to help us progress our agenda, and we are pleased to welcome Dr Zoë Harris to the Trust. Zoë will lead the expansion of R&D across the Trust, helping us to achieve our vision of excellence in R&D at an international level.

Information GovernanceThe Trust has well established arrangements for Information Governance to ensure that information is managed in line with the relevant Information Governance law, regulations and Information Commissioners Office guidance. The arrangements include a Trust-wide Information Governance & IM&T Committee, Trust and Divisional Caldicott Guardians, a Caldicott Guardian for the National Databases and Divisional Information Governance leads.

Audit CommitteeThe Audit Committee operates to the requirements and standards set out in the NHS Wales Audit Committee Handbook and the Trust’s Standing Orders.

Managing Public MoneyThe Trust has well established arrangements in place to ensure it complies with the guidance in Managing Public Money on setting charges for information.

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Velindre NHS Trust

Financial Statement

2014/15

Operating and Financial Review

As a result of the economic climate and the requirement to reduce the level of public spending, the Trust has had to adapt to no increases in funding combined with an increase in demand for high quality service and significant cost pressure. As a result, the Trust primary financial objective during the period was to deliver efficiency savings to offset unfunded cost pressures to allow it to meet its financial duty to breakeven. The Trust will be required to continue to identify efficiency and productivity measures in the future to match cost and service pressures.

On the 1 April 2014 the All Wales Stores Service transferred to the NHS Wales Shared Service Partnership (‘NWSSP’) this included:

Bridgend and Denbigh Stores (transferred from Abertawe Bro Morgannwg UHB). Cwmbran Stores (transferred from Aneurin Bevan UHB).

Commencing on the 4th of February 2015 the NWSSP became the lead employer for GP trainees transferring the payroll arrangements from:

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Darparu ansawdd, gofal a rhagoriaeth

Delivering quality, care & excellence

Aneurin Bevan UHB Abertawe Bro Morgannwg UHB Betsi Cadwaladr UHB Cardiff & Vale UHB Cwm Taff UHB Hywel Dda LHB

There have been no other significant events during 2014/15.

Financial targets The Trust has met three out of its four financial targets for the year ended 31 March 2015:

Breakeven duty - The Trust achieved a surplus of £39,000 in 2014/15 (2013/14: surplus of £57,000) and therefore met its breakeven requirement for the year.

External Finance Limit (EFL) - The Trust is given an External Financing Limit by the Welsh Government which it is permitted to ‘undershoot’ but not exceed. For 2014/15, the Trust met its target, with an ‘undershoot’ of £130,000 (2013/14: undershoot of £62,000). This target demonstrates that the Trust has successfully delivered on its capital programme within the limit set by the Welsh Government.

The NHS Wales Planning Framework for the period 2014 -15 to 2016-17 was issued to NHS Trusts in November 2013. This placed a requirement upon NHS Trusts to prepare and submit Integrated Medium Term Plans to the Welsh Government. The Trust submitted an Integrated Medium Term Plan for the period 2014/15 - 2016/17 in accordance with the NHS Wales Planning Framework, which was subsequently approved by the Minister for Health and Social Services. The Integrated Medium Term Plan relates only to the Velindre NHS Trusts core activities and does not apply to the organisations hosted by the Trust.

Creditor payments - The Trust is required to pay 95% of the number of non-NHS bills within 30 days of the receipt of goods or a valid invoice (whichever is the later). The Trust has not met this target, paying 93.2% (2013/14: 95.4%) within the required time.

Capital Expenditure The aim of the Trust and the wider hosted organisations is to ensure that it invests in the best opportunities to deliver on strategic objectives. Through the systems and controls in place the Trust ensures that capital expenditure is kept withinits capital expenditure limit.

The Trust was provided with a capital allocation of £19,150,000 in 2014/15 (see breakdown below). The following provides details of the capital projects undertaken during the year, analysed by division, and details on capital projects expected over the next few years.

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Major Capital Investments by Service Area

£’000All Wales Funded Capital Schemes Velindre (Cancer Services and Welsh Blood Service) 2,329NWIS 7,267NWSSP 1,833

Discretionary Capital Funded Schemes Velindre (Cancer Services and Welsh Blood Service) 3,494NWIS 2,846NWSSP 804Charitable Funded SchemesVelindre (Cancer Services and Welsh Blood Service) 565

Grant Funded SchemesVelindre (Cancer Services and Welsh Blood Service) 12

Total Capital Schemes 19,150

Velindre NHS Trust (Velindre Cancer Services and Welsh Blood Service)

Capital project Impact Velindre Cancer Centre – First Floor Ward Phase 1 Upgrade(Charitable Funding)

Increased number of personal amenities (toilets and showers) for patients and an en-suite cubicle has been created. Decoration to Female Ward and ancillary accommodation. This has greatly improved the environment, experience and dignity for patients, families and staff. Improved compliance with statutory and mandatory requirements.

Welsh Blood Service – Second Replacement Blood Grouping Analyser and Robotic Sampler(All Wales Capital Funding)

This new equipment will ensure patients have timely access to a safe and sufficient supply of blood, blood products and blood components and will help raise the quality, effectiveness and clinical outcomes of blood and transplant services.

Velindre Cancer Centre – Statutory Compliance

Phase 2 of the First Floor Ward upgrade has begun and is due to be completed in July 2015.

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(All Wales Capital Funding) This will improve the Male Ward significantly in line with the improvements already made to the Female Ward.

Refurbishment of 37 Velindre Place to enable compliance with current statutory and mandatory standards so that it can be utilised by staff, patients or relatives.

Velindre Cancer Centre – IT Infrastructure (Discretionary Capital Funding)

Improved network resilience, network service performance and disaster recovery. Improved IT service performance and connectivity for all users and better desktop support services. Improved compliance with national security standards. Improved wireless networking to support more modern mobile working requirements

Velindre Cancer Centre – Telecommunication and Bleep/Pager Systems(Discretionary Capital)

Purchase of modern and resilient telecommunication and bleep/pager equipment to enhance the staff and patient telephony experience. Introduction of wireless telephony to support more modern mobile working requirements

Welsh Blood Service - Blood Establishment Computer System (Discretionary Capital)

The development of a replacement patient and donor data system that will support the delivery of effective blood services with enhanced capability. The system went live in May 2015.

As well as the above major capital projects, discretionary capital funding was used to purchase assets which supported the operational effectiveness of Velindre Cancer Centre and Welsh Blood Service. The assets purchased included patient monitors, two chemotherapy dispensary vending machines, thermocyclers, a plate reader, catering equipment and a delivery vehicle.

Looking forward to 2015/16, the Velindre Cancer Centre is continuing to develop plans for Cancer Services in South East Wales which brings together the best possible patient care and environment with the voluntary sector, leading edge research and development with academia. The Welsh Blood Service is in the process of developing plans to create an All Wales Blood Service as North Wales collection and supply is currently undertaken by a specialist Health Authority in England.

NHS Wales Informatics Service (NWIS) The purpose of NWIS is to invest in the best opportunities to strategically develop Information Communication Technology (ICT), to deliver operational ICT services and to improve information

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management across the NHS in Wales. As much of the expenditure incurred relates to software, it is classified as an intangible fixed asset.

Capital project Impact 2014-15* Microsoft Lync Lync will support LHB and Trust staff to work

more efficiently and to collaborate more easily to support the health and wellbeing of the citizens of Wales. Lync will provide many benefits, including: Allowing NHS staff to use video conferencing and instant messaging with patients/carers/support workers that are out in the community. Supporting virtual Multi Disciplinary Team (MDT) meetings, in particular for those working in the community who do not have access to the current Video Conferencing service. Using Lync, a video conferencing session can easily be established on smartphones, tablets or laptops between various staff in any geographical location.

Welsh Clinical Portal (WCP) The system will consolidate patient information to one portal, where it is currently held across a number of computer systems and databases. The key benefit being that it will allow healthcare practitioners an immediate and complete view of the important data in order to make vital clinical decisions. The system also includes some additional functionality for improving the effectiveness of key tasks.

Welsh Care Records Service Enabling access to health and care records wherever care is delivered has been a consistent strategic aim. This project will provide a Common Care record where different organisations and services can contribute documents into a single shared record with controlled access and thus enable the transition to a shared electronic record across multidisciplinary care services and clinical networks and between health and social care.

Laboratory Information Management System (LIMS)

This project is a collaboration between the Pathology Service, the Pathology Modernisation Agenda for Wales and NHS Wales Informatics

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Service, to procure and implement a new Laboratory Information Management System.

Emergency Department Clinical Information Management System

NHS Wales Informatics Service (Informatics Service) managed a procurement on behalf of NHS Wales Health Boards and Trusts to establish an appropriate contractual arrangement to enable the phased implementation of an Emergency Department Clinical Information and Management System (EDCIMS) across NHS Wales with a common solution that enables Health Boards to procure and implement a new suite of applications, hardware and services to support the ongoing delivery of Emergency Services. This will provide a consistent approach to emergency care management across NHS Wales.

NHS Wales Shared Services Partnership (NWSSP)

Major Capital project Impact Establishment of a South East Regional Centre at Companies House

This project started during the 2013/14 Capital programme and was completed in September 2014. Following completion of the project over 500 staff moved into accommodation in Companies House in Cardiff in September/October 2014.

Student Bursary IT Software Procurement & Implementation

This project was initiated during the 2013/14 Capital programme and was completed in November 2014. The system went live in December 2014 and was used by all new bursary applicants for the March 2015 student intake.

Health Courier Service (HCS) Vehicle Replacement

This involved the replacement of a number of vehicles for HCS who transferred to NWSSP from Welsh Ambulance Service NHS Trust with effect from 1st April 2015. Funding was also utilised to procure additional vehicle handsets for the Cleric Vehicle Management system

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NWSSP also had an Initial annual discretionary capital allocation of £200,000 and this was further augmented during the year by an additional discretionary allocation of £604,000.

This funding is utilised to ensure business continuity and to support local improvement schemes. During the year, £522,000 was invested in the Information Technology improvement and refresh programme which includes both hardware and software. An investment of £205,000 was used to develop the stores locations to meet current and future operational needs and £50,000 was invested in Replacement forklifts trucks. The final £27,000 of discretionary funding was utilised to improve document handling with the Primary Care Services function.

2015/16 will see the completion of phase 2 of the capital works within the South East Regional Centre at Companies House and further investment will be made in IT Hardware and Software. This investment will improve service efficiency and is part of the NWSSP’s Integrated Medium Term Plan.

Summary Financial Statements The following Financial Statements are a summary of the full set of accounts for the year 1 April 2014 to 31 March 2015. As a summary these financial statements might not contain sufficient information for a full understanding of the Trust’s financial position and performance. A full copy of the annual accounts can be obtained from: Mr Mark Osland, Interim Director of Finance, Velindre NHS Trust, 2 Charnwood Court, Heol Billingsley, Parc Nantgarw, Cardiff, CF15 7QZ

The Auditor General for Wales has issued an unqualified report on the full version of these accounts and the Audit Report on page 135 provides assurance that the summary financial statements are consistent with the full financial accounts.

Accounting PoliciesThe accounts for the period ended 31 March 2015 have been prepared to comply with International Financial Reporting Standards (IFRS) in accordance with HM Treasury’s I-FReM.

In the prior year, following adoption of IAS 27 ‘Consolidated and Separate Financial Statements’ which became effective for NHS bodies on the 1 April 2013, the Velindre NHS Trust Charitable Funds have been consolidated in to the financial statements of the Trust. Details of the impact of adopting IAS 27 are provided in the financial statements. The consolidated financial statements incorporate the results of Velindre NHS Trust 'the Trust'

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and its subsidiary undertaking, Velindre NHS Trust Charitable Funds. The comparative period within the full and summary financial statements has been restated to include Velindre NHS Trust Charitable Funds. The impact of the comparative consolidation is reflected throughout the primary financial statements and the related notes. All intra group transactions, balances, income and expenses are eliminated on consolidation.

The particular accounting policies adopted by the Trust are described in the Trust Financial statements.

Pension Liabilities Past and present employees are covered by the provisions of the NHS Pension Scheme. Details of how the scheme is operated are provided in note 12 of the Trust’s Financial statements.

Auditor remuneration Fees paid to the Wales Audit Office for the statutory audit were £201,000.

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Statement of comprehensive income for the year ending 31 March 2015

NHS Trust Consolidated

2014-15 2013-14 2014-15 2013-14

£000 £000 £000 £000

Revenue from patient care activities 242,126 222,482 242,126 222,482

Other operating revenue 237,218 195,248 238,165 196,863

Operating expenses (479,457) (417,718) (480,489) (418,175)

Operating surplus/(deficit) (113) 12 (198) 1,170

Investment revenue 51 84 114 141

Other gains and losses 6 112 6 112

Finance costs 672 (151) 672 (151)

Consolidated - Retained Surplus/(deficit) 594 1,272

NHS Trust Breakeven Duty - Retained surplus/(deficit) 616 57

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Statement of financial position at 31 March 2015 NHS Trust Consolidated 31 March 31 March 31 March 31 March 2015 2014 2015 2014 £000 £000 £000 £000 Non-current assets Property, plant and equipment 90,216 84,816 90,216 84,816 Intangible assets 27,575 25,796 27,575 25,796 Trade and other receivables 459,910 417,597 459,910 417,597 Other financial assets - - 3,321 2,057 Total non-current assets 577,701 528,209 581,022 530,266 Current assets Inventories 5,530 1,622 5,530 1,622 Trade and other receivables 264,796 211,047 264,927 211,969 Other financial assets - - - -Cash and cash equivalents 10,527 13,041 11,599 14,297 280,853 225,710 282,056 227,888 Non-current assets held for sale - - - -Total current assets 280,853 225,710 282,056 227,888 Total assets 858,554 753,919 863,078 758,154 Current liabilities Trade and other payables (68,955) (54,436) (69,274) (54,637) Borrowings (57) (50) (57) (50) Other financial liabilities - - - -Provisions (207,270) (170,558) (207,270) (170,558) Total current liabilities (276,282) (225,044) (276,601) (225,245) Net current assets/(liabilities) 4,571 666 5,455 2,643 Total assets less current liabilities 582,272 528,875 586,477 532,909 Non-current liabilities Trade and other payables (221,786) (210,569) (221,786) (210,569) Borrowings (13) (57) (13) (57) Other financial liabilities - - - -Provisions (238,512) (210,910) (238,512) (210,910) Total non-current liabilities (460,311) (421,536) (460,311) (421,536) Total assets employed 121,961 107,339 126,166 111,373 Financed by Taxpayers' equity: Public dividend capital 84,383 72,763 84,383 72,763 Retained earnings 12,404 11,736 12,404 11,736 Revaluation reserve 25,174 22,840 25,174 22,840 Other reserves - - - -Funds Held on Trust Reserves - - 4,205 4,034 Total taxpayers' equity 121,961 107,339 126,166 111,373

The financial statements were approved by the Audit Committee on behalf of the Board on 4th June 2015 signed on behalf of the Board by: Steve Ham, Chief Executive:

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Statement of changes in taxpayer equity at 31 March 2015

Public

Dividend Capital

Retained earnings

Revaluation reserve

Other reserves

TotalFHOT

ReservesConsolidated

Total

£000 £000 £000 £000 £000 £000 £000 Balance at 1 April 2014 72,763 11,736 22,840 - 107,339 4,034 111,373 Retained surplus/(deficit) for the year - 616 - - 616 - 616 Net gain/(loss) on revaluation of property, plant and equipment - - 2,386 - 2,386 - 2,386 Net gain/(loss) on revaluation of intangible assets - - - - - - -Net gain/(loss) on revaluation of financial assets - - - - - 193 193 Net gain/(loss) on revaluation of PPE and Intangible assets held for sale - - - - - - -Net gain/(loss) on revaluation of financial assets held for sale - - - - - - -Impairments and reversals - - - - - - -Movements in other reserves - 52 (52) - - - -Transfers between reserves - - - - - - -Net gain/loss on Other Reserve (specify) - - - - - - -Reclassification adjustment on disposal of available for sale financial assets - - - - - - -Reserves eliminated on dissolution - - - - - - -New Public Dividend Capital received 11,693 - - - 11,693 - 11,693 Public Dividend Capital repaid in year - - - - - - -Public Dividend Capital extinguished/written off - - - - - - -Other movements in PDC in year (73) - - - (73) - (73)FHoT – Endowment - - - - - 326 326 FHoT – Restricted - - - - - (348) (348)FHoT - Unrestricted - - - - - - -Balance at 31 March 2015 84,383 12,404 25,174 - 121,961 4,205 126,166

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Statement of cash flows for the year ended 31 March 2015 NHS Trust Consolidated

2014-15 2013-14 2014-15 2013-14 £000 £000 £000 £000 Cash flows from operating activities Operating surplus/(deficit) (113) 12 (198) 1,170 Depreciation and amortisation 14,518 11,994 14,518 11,994 Impairments and reversals (158) - (158) -Release of PFI deferred credits - - - -Donated Assets received credited to revenue but non-cash (565) (7) (565) (7) Government Granted Assets received credited to revenue but non-cash (12) - (12) -Interest paid (7) (29) (7) (29) (Increase)/decrease in inventories (3,908) 1,027 (3,908) 1,027

(Increase)/decrease in trade and other receivables(96,104

) (76,900) (95,313) (77,464) Increase/(decrease) in trade and other payables 27,144 33,787 27,260 33,863 Increase/(decrease) in provisions 64,993 42,972 64,993 42,972 Net cash inflow from operating activities 5,788 12,856 6,610 13,526 Cash flows from investing activities Interest received 51 84 114 141

(Payments) for property, plant and equipment(10,935

) (12,095) (10,935) (12,095) Proceeds from disposal of property, plant and equipment 6 112 6 112 (Payments) for intangible assets (9,080) (14,397) (9,080) (14,397) Proceeds from disposal of intangible assets - - - -(Payments) for investments with Welsh Government - - - -Proceeds from disposal of investments with Welsh Government - - - -(Payments) for financial assets. - - (1,724) (929) Proceeds from disposal of financial assets. - - 655 934 Rental proceeds - - - -

Net cash (outflow) from investing activities(19,958

) (26,296) (20,964) (26,234)

Net cash (outflow)/inflow before financing(14,170

) (13,440) (14,354) (12,708) Cash flows from financing activities Public Dividend Capital received 11,693 10,844 11,693 10,844 Public Dividend Capital repaid - - - -Loans received from Welsh Government - - - -Other loans received - - - -Loans repaid to Welsh Government - - - -Other loans repaid - - - -Other capital receipts - - - -Capital elements of finance leases and on-SOFP PFI (37) (56) (37) (56) Cash transferred (to)/from other NHS Wales bodies - - - -Net cash (outflow) from financing activities 11,656 10,788 11,656 10,788 Net (decrease) in cash and cash equivalents (2,514) (2,652) (2,698) (1,920) Cash [and] cash equivalents 13,041 15,693 14,297 16,217 at the beginning of the financial year

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Cash [and] cash equivalents at the end of the financial year 10,527 13,041 11,599 14,297

Remuneration Report The pay and terms and conditions of employment for the Executive Team and senior managers have been, and will be determined by the Velindre NHS Remuneration and Terms of Service Committee, within the framework set by the Welsh Government. The Remuneration and Terms of Service Committee also considered and approved applications relating to the voluntary release scheme. The Trust Remuneration Committee members are all Independent Members of the board and the Committee is chaired by the Trust Chairman.

Existing public sector pay arrangements apply to all staff including members of the Executive Team. In 2014-15, no increases to salary for members of the Executive Team were considered or approved by the Remuneration and Terms of Service Committee. Additionally, all members of the Executive Team are on pay points and not pay scales and therefore no member of the Executive Team were entitled to or received any incremental increase in salary during 2014-15.

Performance of members of the Executive Team is assessed against personal objectives and against the overall performance of the Trust. The Trust does not operate a performance related pay scheme. All Executive Directors have the option to have a lease car, under the terms of the Trust’s lease car agreement.

The Chief Executive and Executive Directors are employed on permanent contracts, which can be terminated by giving due notice unless for reasons of misconduct.

During 2014-15 the Remuneration Committee approved the following:

An interim salary of £127,000, pro-rata for the year from 1 April 2014 to 4 January 2015 for Mr Steve Ham, Interim Chief Executive, to reflect his appointment as interim Chief Executive from 1 April 2014. An interim salary of £134,000 pro rata was agreed from the 5 January 2015 to reflect his taking on Accountable Officer status as Interim Chief Executive.

The remuneration Committee also considered and approved applications relating to the voluntary early release scheme (‘VERs’). Full details of compensation paid under the VERs scheme are shown below.

There have been no payments to former Executives or other former senior Managers during the year.

Payments have been made to the Welsh Government for the services of the Interim Director of Finance who is on secondment. There have been no payments for any professional indemnity insurance for an Officer or Director.

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The remuneration report is required to contain information about senior manager’s remuneration. The senior management team consists of the Chief Executive, the Executive Directors and the Non-executive directors. Full details of senior managers’ remuneration are given in the tables below. Salary and Pension Disclosure Tables – Single total figure of remuneration The Remuneration Report includes a Single Total Figure of Remuneration. This is a different way of presenting the remuneration for each individual for the year. The table used is similar to that used previously, and the salary and benefits in kind elements are unchanged. The amount of pension benefits for the year which contributes to the single total figure is calculated in the following way, similar to the method used to derive pension values for tax purposes, and is based on information received from NHS BSA Pensions Agency.

The value of pension benefits is calculated as follows:

(real increase in pension* x 20) + (real increase in any lump sum*) – (contributions made by member)

*excluding increases due to inflation or any increase of decrease due to a transfer of pension rights

The amount included in the table for pension benefit is based on the increase in accrued pension adjusted for inflation. This will generally take into account an additional year of service together with any changes in pensionable pay. This is not an amount which has been paid to an individual by the Trust during the year; it is a calculation which uses information from the pension benefit table. These figures can be influenced by many factors e.g. changes in a person’s salary, whether or not they choose to make additional contributions to the pension scheme from their pay and other valuation factors affecting the pension scheme as a whole.

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Salary and Pension Disclosure Tables – Single total figure of remuneration (continued) 2014-15 2013-14Name and Title Salary

(bands of £5,000)

Other Remunera

tion (bands of

£5000)

Benefits in Kind (to

the nearest £100)

Pension benefits (to the nearest £1000)

Total (to the

nearest £1,000)

Salary (bands of £5,000)

Other Remunera

tion (bands of

£5000)

Benefits in Kind (to the

nearest £100)

Pension benefits (to the nearest

£1000)

Total (to the nearest £1,000)

Restated RestatedExecutive Directors

Simon Dean, Accountable Officer 2

- - - - - 130-135 - 3 8 140-145

Steve Ham, Interim Chief Executive 3

125-130 - 2 135 260-265 100-105 - 8 7 105-110

Mark Osland, Interim Executive Director of Finance 4

30-35 - - - 30-35 - - - - -

Peter Barrett-Lee, Medical Director

30-35 110-115 2 - 141-145 30-35 110-115 2 - 141-145

Susan Morgan, Executive Director of Nursing and Service Improvement

95-100 - - - 95-100 95-100 - - - 95-100

Sarah Morley, Executive Director of OD and Workforce 5

60-65 0 1 33 95-100 - - - - -

Senior Manager

Carl James, Director of Planning, Performance & Estates 6

95-100 - 19 4 100-105 95-100 - 34 - 95-100

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Non Executive Directors

R Kennedy 1 40-45 - - - 40-45 40-45 - - - 40-45P Griffiths 5-10 - 4 - 5-10 5-10 - 3 - 5-10H Ludgate 5-10 - 1 - 5-10 5-10 - 1 - 5-10R Singh 5-10 - 4 - 5-10 5-10 - 7 - 5-10P Roberts 5-10 - - - 5-10 5-10 - 6 - 5-10J Hopkinson 5-10 - - - 5-10 5-10 - 1 - 5-10J Pickles 5-10 - - - 5-10 5-10 - 1 - 5-10

Restatement of comparative information The comparative pension benefits have been restated for those individuals where the calculation gave a negative figure. In these instances, the disclosure shown for 2013-14 will not agree to the prior year Annual Report.Notes

1. In January 2015, Professor Rosemary Kennedy was re-appointed by the Minister for Health & Social Services as Chair of Velindre NHS Trust for another four year term following her initial appointment in January 2011.

2. Simon Dean held Accountable Officer status until the 4 January 2015. The full cost of his remuneration was recharged to Welsh Government therefore no remuneration has been shown for 2014-15.

3. Steve Ham was appointed Acting Chief Executive on 1 April 2014, in addition to retaining his role as the Executive Director of Finance. On the 4 January 2015, he relinquished his role as Executive Director of Finance, taking on the role of Interim Chief Executive and Accountable Officer status with effect from 5 January 2015.

4. Mark Osland was appointed Interim Executive Director of Finance on 6 January 2015 and is on secondment from Welsh Government. The amount shown in the salary column within the single total figure of remuneration above represent the full cost of his employment, which is recharged from the employing organisation, Welsh Government to Velindre NHS Trust.

5. Sarah Morley joined Velindre NHS Trust as Executive Director of Workforce and OD on the 1 July 20146. Whilst not an Executive Director, Carl James Director of Capital, Planning and Estates is considered to be a Senior Manager of the Trust

and therefore included within the remuneration report. Comparative information for 2013-14 has been provided.

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Salary and Pension Disclosure Tables – Board member pensions

Name and Title Real increase in pension at age 60 (bands

of £2,500)

Real increase in pension lump sum at aged 60 (bands

of £2,500)

Total accrued pension at age 60 at 31 March 2015 (bands of £5,000)

Lump sum at age 60 related to

accrued pension at 31 March 2015 (bands of £5,000)

Cash Equivalent Transfer Value at 31 March 2015

Cash Equivalent Transfer Value at 31 March 2014

Real increase in Cash Equivalent Transfer Value

Employer’s contribution to

stakeholder pension

£000 £000 £000 £000 £000 £000 £000 £000Directors

Steve Ham, Interim Chief Executive

5 - 7.5 15-20 25-30 80-85 574 424 150 -

Peter Barrett-Lee, Medical Director

0-2.5 0-2.5 55-60 165-170 1,242 1,200 42 -

Susan Morgan, Director of Nursing

0-2.5 0-2.5 30-35 100-105 681 655 27 -

Sarah Morley, Executive Director of Workforce and OD

0-2.5 5-7.5 15-20 45-50 282 228 41 -

Senior Manager Carl James, Director of Planning, Performance & Estates

0-2.5 0- 2.5 25-30 0 286 271 15 -

Notes: Mark Osland, Interim Executive Director of Finance is on secondment from Welsh Government and his future pension liability will be met by the Welsh Government through the civil service pension scheme and therefore disclosures regarding his pension have not been included in the above table. As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members.

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Cash Equivalent Transfer ValuesA 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 an arrangement to secure pension benefits in another pension scheme or an 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. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.

Real Increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period.

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Reporting of other compensation schemes – exit packagesThe Trust operates a Voluntary Early Release Scheme, following all Wales guidelines and process. This is available to all staff and all applications are considered by local managers and Directors and ultimately the Remuneration Committee.

2014-15 2013-14

Exit packages cost band (including any special payment element)

Number of compulsory

redundancies

Number of other

departures

Total number of exit packages

Number of departures where special payments have been made

Total number of exit packages

Whole numbers onlyWhole

numbers only Whole numbers only Whole numbers only Whole numbers onlyless than £10,000 3 1 4 - 6£10,000 to £25,000 1 2 3 - 7£25,000 to £50,000 1 4 5 - 7£50,000 to £100,000 - 1 1 - 1£100,000 to £150,000 - - - - -£150,000 to £200,000 - - - - -more than £200,000 - - - - -Total 5 8 13 - 21 2014-15 2013-14Exit packages cost band (including any special payment element)

Cost of compulsory redundancies

Cost of other departures

Total cost of exit packages

Cost of special element included in exit packages

Total cost of exit packages

£ £ £ £ £less than £10,000 15,328 9,293 24,621 - 31,143£10,000 to £25,000 12,624 37,430 50,054 - 118,583£25,000 to £50,000 32,740 142,077 174,817 - 219,163£50,000 to £100,000 - 98,453 98,453 - 57,000£100,000 to £150,000 - - - - -£150,000 to £200,000 - - - - -more than £200,000 - - - - -Total 60,692 287,253 347,945 - 425,889

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Redundancy and other departure costs have been paid in accordance with the provisions of the NHS scheme or the trust Voluntary Early Release Scheme. Exit costs in this note are accounted for in full in the year of departure. Where the Trust has agreed early retirements, additional costs are met by the trust and not by the NHS pension’s scheme. Ill-health retirement costs are met by the NHS pension’s scheme and are not included in the table.

This disclosure reports the number and value of exit packages taken by staff leaving this year. Note: the expense associated with these departures may have been recognised in part or in full in a previous period.

Remuneration Relationship Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation’s workforce. The banded remuneration of the highest-paid director in Velindre NHS Trust in the financial year 2014-15 was £125,000 - £130,000 (2013-14, £130,000 - £135,000). This was 4.9 times (2013-14, 5.3) the median remuneration of the workforce, which was £26,000 (2013-14, £25,000).

In 2014-15, 7 (2013-14, 4) employees received remuneration in excess of the highest-paid director. These employees are Medical Consultants. Remuneration ranged from £14,000 to £176,000 (2013-14 £14,000 -£154,000).

Total remuneration includes salary, non-consolidated performance-related pay and benefits-in-kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions. Overtime payments are included in the calculation of both elements of the relationship.

In establishing the highest paid Director (Chief Executive) the Trust has taken into account the proportion of remuneration received by Directors for Clinical and Director responsibilities.

2014-2015 2013-2014Band of Highest paid Director’s TotalRemuneration £000

125-130 130-135

Median Total Remuneration £000 26 25

Ratio 4.9:1 5.3:1

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Tax Assurance for Off-Payroll EngagementsFollowing the Review of Tax Arrangements of Public Sector Appointees published by the Chief Secretary to the Treasury on 23 May 2012, departments must publish information on their highly paid and/or senior off-payroll engagements. The information, contained in the three tables below, includes all off-payroll engagements as at 31 March 2015 for those earning more than £220 per day and that last longer than six months for the core Department, its Executive Agencies and its arm’s length bodies.

Table 1: For all off-payroll engagements as of 31 March 2015, for those earning more than £220 per day and that last for longer than six months

Velindre

No. of existing engagements as of 31 March 2015 25

Of which...

No. that have existed for less than one year at time of reporting. 6

No. that have existed for between one and two years at time of reporting.

12

No. that have existed for between two and three years at time of reporting.

2

No. that have existed for between three and four years at time of reporting.

4

No. that have existed for four or more years at time of reporting. 1

Within the total number of off-payroll engagements disclosed, 9 engagements related to staff seconded from other NHS Wales Organisations and 1 engagement related to a Welsh Local Authority.

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Table 2: For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2014 and 31 March 2015, for more than £220 per day and that last for longer than six months

Velindre

No. of new engagements, or those that reached six months in duration, between 1 April 2014 and 31 March 2015

7

No. of the above which include contractual clauses giving the department the right to request assurance in relation to income tax and National Insurance obligations

6

No. for whom assurance has been requested 7

Of which...

No. for whom assurance has been received 5

No. for whom assurance has not been received 2

No. that have been terminated as a result of assurance not being received.

0

Within the total number of new off-payroll engagements disclosed, 1 engagement related to staff seconded from another NHS Wales Organisation.

*The 2 for whom assurance has not been received have finished their assignments and are no longer engaged by the Trust.

Table 3: For any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2014 and 31 March 2015

No. of off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year.

0

No. of individuals that have been deemed “board members, and/or, senior officials with significant financial responsibility”, during the financial year. This figure should include both off-payroll and on-payroll engagements.

0

This disclosure note is not subject to audit and is not covered by the Audit Report on page 135.

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Statement of Chief Executive’s responsibilities as Accountable Officer of the Trust.

The Welsh Ministers have directed that the Chief Executive should be the Accountable Officer to the Trust. The relevant responsibilities of Accountable Officers, including their responsibility for the propriety and regularity of the public finances for which they are answerable, and for the keeping of proper records, are set out in the Accountable Officer’s Memorandum issued by the Welsh Government.

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in my letter of appointment as an Accountable Officer.

Signed: Steve HamChief Executive 4 June 2014

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Statement of Directors Responsibilities in Respect of the Accounts

The directors are required under the National Health Service (Wales) Act 2006 to prepare accounts for each financial year. The Welsh Ministers, with the approval of the Treasury, directs that these accounts give a true and fair view of the state of affairs of the Trust and of the income and expenditure of the NHS Trust for that period. In preparing those accounts, the directors are required to:

apply on a consistent basis accounting principles laid down by the Welsh Ministers with the approval of the Treasury;

make judgements and estimates which are responsible and prudent; state whether applicable accounting standards have been followed, subject to any

material departures disclosed and explained in the account.

The directors confirm they have complied with the above requirements in preparing the accounts. The directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the Trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned direction by the Welsh Ministers.

By Order of the BoardSigned:

Rosemary KennedyTrust Chair

Date: 4th June 2015

Steve HamChief Executive

Date: 4th June 2015

Mark OslandDirector of Finance

Date: 4th June 2015

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Report of the Auditor General for Wales to the National Assembly for Wales on the Summary Financial Statements

I have examined the summary financial statements contained in the Annual Report of Velindre NHS Trust on pages 118 to 130.

Respective responsibilities of the Accountable Officer and auditor.The Accountable Officer is responsible for preparing the Annual Report. My responsibility is to report my opinion on the consistency of the summary financial statements with the statutory financial statements, and the auditable part of the remuneration report. I also read the other information contained in the Annual Report and consider the implications for my report if I become aware of any misstatements or material inconsistencies with the summary financial statements and the full financial statements.

Basis of opinionI conducted my work in accordance with Bulletin 2008/3 ‘The auditor’s statement on the summary financial statements’ issued by the Financial Reporting Council for use in the United Kingdom.

OpinionIn my opinion the summary financial statements are consistent with the statutory financial statements and the auditable part of the remuneration report of Velindre NHS Trust for the year ended 31 March 2015 on which I have issued an unqualified opinion. I have not considered the effects of any events between the dates on which I signed my report on the full financial statements, 23 June 2015 and the date of this statement.

I placed a substantive report on accounts explaining the new financial duties of NHS Trusts for 2014-15 onwards, Velindre NHS Trust’s performance against them, and the implications for 2015-16. This report can be found with the statutory financial statements.

In my opinion the information contained in the Annual Report for the financial year for which the financial statements are prepared is consistent with both the summary and the full financial statements.

Huw Vaughan Thomas Wales Audit OfficeAuditor General for Wales 24 Cathedral Road8th Sept 2015 Cardiff

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The maintenance and integrity of the Velindre NHS Trust website is the responsibility of the Accounting Officer; the work carried out by auditors does not involve consideration of these matters and accordingly auditors accept no responsibility for any changes that may have occurred to the financial statements since they were initially presented on the website.

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