Annual Report and Accounts - The Great Western Hospital

More documents

Recommendations

Info

No. Audit Title Audit Summary/Learning and Action Neighbourhood Teams 43. Services in the Swindon Community for Children with Continuing Healthcare Needs 44. Management of Suspected Cardiac Chest Pain in the Emergency Department 45. Compliance with Discharge Summaries Audit Report-Quality & Timeliness 2011- 12 46. Compliance with Out Patient Clinic Letters-2011-12 47. Continuing Health Care (CHC) Review Process 48. Community Patients have an Estimated Date of Discharge (EDD) in their Care Plans (Re-Audit) 49. Congenital Hypothyroidism Excellent practice demonstrated around identifying acting upon and documenting the children’s clinical need. Further work includes improved documentation of care for children with complex healthcare needs and development of local guidelines. Very high compliance. Actions include changes to a few sections of the “Chest Pain Proforma”. The re-audit showed that the Trust has demonstrated high compliance with the vast majority of the standards. ALL electronic discharge summaries currently submitted now have values for the data on: Action by GP requested / For GP info, Urgent / Routine, Medication Changed (Y/N). Finally, compliance with the timeliness of inpatient discharge summaries to be with GPs within 1 working day of discharge was 73% (Target-90%). Actions include: dissemination of results, weekly monitoring on timeliness of eDS and educating all clinicians to ensure discharge summaries include all relevant information. The re-audit demonstrated that the vast majority (94%) of the patient records checked reflect a high standard of compliance. Considering that changes to the OP clinic template were implemented on 12th Jan 2012, the compliance with data on: Action by GP requested / For GP info, Urgent / Routine, Medication Changed (Y/N), is 80% (Target-98%).Furthermore, it was observed that the actions in the boxes did match the content/sense of the OP clinic letter. Even though there is some improvement with the availability of clinic letter on Medway within 2 working days, there is further improvement required to achieve compliance (% Achieved- 71%, Target- 90%). Actions include: Dissemination of results, continue work on improving timeliness of clinic letters and re-evaluate the effectiveness of the mandatory boxes. Audit identified that, although improvements have been made, further work is required in order that all documents are completed ensuring that all areas of patient need are being met. 7 Neighbourhood Teams have achieved 100% compliance with EDD set and documented within 24 hours. Action includes, non-compliance NT’s to benchmark against each other to improve compliance. There is clear evidence of good documentation and institution of treatment and investigation in children born with CHD. In addition, the follow-up is also managed regularly. Page 100 of 211
No. Audit Title 50. NICE CG111 – Nocturnal Enuresis 51. Readmission Review – Unscheduled Care 52. Readmission Review –Planned Care Audit Summary/Learning and Action Although the Children’s Continence Service has achieved 100% compliance against the majority of the criteria, the Care Pathway needs to be revised to include the latest published NICE Guidance. The review results demonstrate that there is no evidence that suggests any gaps in delivery of care. None of the readmissions were preventable or avoidable. The review results demonstrate that there is no evidence that suggests any gaps in delivery of care. Relevant information was provided to all of the patients on discharge. Furthermore, there is no evidence of failure to communicate between acute care and primary care. 100% of patients reviewed showed no evidence of any issues concerning community care prior to readmission. It is recommended that further audits are undertaken to raise any clinical areas of concern and to ensure appropriate financial credits with commissioners. It is also recommended that this work links in with the ongoing Surgical Site Infection (SSI) audit work to identify and potential areas of concern regarding infection rates. 6.3.2 Participation in Clinical Research The number of patients receiving NHS services provided or sub-contracted by Great Western Hospitals NHS Foundation Trust that were recruited during that period to participate in research approved by a research ethics committee was 793. 6.3.3 Use of the CQUIN Framework A proportion of Great Western Hospitals NHS Foundation Trust income in 2011/12 was conditional upon achieving quality improvement and innovation goals agreed between Great Western Hospitals NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2011/12 and for the following 12 month period are available online at: http://www.monitornhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=3275 Page 101 of 211
Page 1:
Great Western Hospitals NHS Foundat
Page 5 and 6:
CONTENTS 1 Chair and Chief Executiv
Page 7 and 8:
The Great Western Hospital became a
Page 9 and 10:
Underpinning this, our values are t
Page 11 and 12:
3.2 Principal activities of the Tru
Page 13 and 14:
Further Companies Act Disclosures 3
Page 15 and 16:
Business Review / Management Commen
Page 17 and 18:
3. To ensure that staff are proud t
Page 19 and 20:
6. To work in partnership with othe
Page 21 and 22:
With funding received from the Depa
Page 23 and 24:
3.13 Contractual arrangements The T
Page 25 and 26:
Patient care 3.16 Development of se
Page 27 and 28:
3.20 New or significantly revised s
Page 29 and 30:
3.24 Complaints Handling For the Tr
Page 31 and 32:
The Trust actively responds to feed
Page 33 and 34:
3.25 Using patient experience to dr
Page 35 and 36:
The table below shows the CQUIN res
Page 37 and 38:
Action plans based on the Quarterly
Page 39 and 40:
3.27 Development of services with o
Page 41 and 42:
3.29 Health and Overview Scrutiny C
Page 43 and 44:
3.32.5 Interests held by Directors
Page 45 and 46:
4.3 Attendance at meetings of the R
Page 47 and 48:
4.7 Board of Directors’ employmen
Page 49 and 50: Remuneration Name Title Salary (Ban
Page 51 and 52: 4.8.4 Additional disclosures The Tr
Page 53 and 54: 5.1.2 Elected Governors - Public Co
Page 55 and 56: 5.1.4 Nominated Governors Name Nomi
Page 57 and 58: 5.1.6 Lead and Deputy Lead Governor
Page 59 and 60: “Eyes and Ears” - An initiative
Page 61 and 62: 5.1.12 Nominations and Remuneration
Page 63 and 64: Rowland Cobbold, Non-Executive Dire
Page 65 and 66: Lyn Hill-Tout, Chief Executive (unt
Page 67 and 68: 5.2.3 Length of appointments of Non
Page 69 and 70: 5.2.6 Attendance at meetings of the
Page 71 and 72: 5.3 Audit Committee 5.3.1 The Audit
Page 73 and 74: 5.4 Directors’ responsibility for
Page 75 and 76: Note: Angela Gillibrand and Rowland
Page 77 and 78: The Mental Health Act / Mental Capa
Page 79 and 80: The Trust has a wide range of staff
Page 81 and 82: 5.8.6 Membership Strategy To encour
Page 83 and 84: 5.9 Code of Governance Disclosure S
Page 85 and 86: 6 QUALITY REPORTS Part 1 - Statemen
Page 87 and 88: Part 2 - Priorities for improvement
Page 89 and 90: 6.3.1 Review of services and partic
Page 91 and 92: The trust chose not to contribute t
Page 93 and 94: No. Audit Title Reconstruction Audi
Page 95 and 96: The reports of 273 local clinical a
Page 97 and 98: No. Audit Title 15. Non Invasive Ve
Page 99: No. Audit Title Antibiotic Prescrib
Page 103 and 104: Great Western Hospitals NHS Foundat
Page 105 and 106: Part 3 - Other Information 6.4 Over
Page 107 and 108: GRAPH - Clostridium Difficile WCHS2
Page 109 and 110: GRAPH - Medicine incidents by type
Page 111 and 112: Harm from falls WCHS: It was not po
Page 113 and 114: • Rolling educational programme w
Page 115 and 116: CHART - Relative risk SW Acute Trus
Page 117 and 118: Following the Trust’s merge in Ju
Page 119 and 120: Priority 7: Participation on the Re
Page 121 and 122: All the guidelines have been dissem
Page 123 and 124: This has been achieved by: • Mont
Page 125 and 126: • As a result of complaints and c
Page 127 and 128: CHART - National Sentinel Stroke Au
Page 129 and 130: Priority 16: To ensure patients are
Page 131 and 132: 6.5 Care Quality Commission (CQC) I
Page 133 and 134: 6.7 Statement of Directors’ respo
Page 135 and 136: a Quality Account and the opportuni
Page 137 and 138: Overall, the Trust has good plans t
Page 139 and 140: Page 139 of 211
Page 141 and 142: Graph 1 - GWH carbon footprint (ton
Page 143 and 144: The Trust is working with local bus
Page 145 and 146: Graph 9 - Total tonnes of waste pro
Page 147 and 148: The Trust will be working towards a
Page 149 and 150: Detailed below is a summary of the
Page 151 and 152:
Wiltshire Community Health Services
Page 153 and 154:
providers. Feedback obtained across
Page 155 and 156:
The Musculoskeletal Disorder team a
Page 157 and 158:
10.2.2 Governance risk rating The t
Page 159 and 160:
11 OTHER DISCLOSURES IN PUBLIC INTE
Page 161 and 162:
13 AUDITOR’S OPINION AND CERTIFIC
Page 163 and 164:
14 ANNUAL GOVERNANCE STATEMENT 14.1
Page 165 and 166:
• the key controls to mitigate ag
Page 167 and 168:
14.4.6 Organisation Culture The Tru
Page 169 and 170:
14.5 Review of economy, efficiency
Page 171 and 172:
Process Board Role and Conclusions
Page 173 and 174:
15 GLOSSARY OF TERMS BARS - Blood A
Page 175 and 176:
16 FOREWORD TO THE ACCOUNTS 16.1 Fo
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
Page 203 and 204:
Page 205 and 206:
Page 207 and 208:
Page 209:
Page 214:
Page 217 and 218:
1 CHAIR AND CHIEF EXECUTIVE’S REP
Page 219 and 220:
2 OUR TRUST 2.1 Vision - Your healt
Page 221 and 222:
3 DIRECTOR’S REPORT General Compa
Page 223 and 224:
3.3.2 The Brunel Treatment Centre O
Page 225 and 226:
14 In relation to the use of financ
Page 227 and 228:
Checklist, a World Health Organisat
Page 229 and 230:
organisations to adapt to these cha
Page 231 and 232:
TABLE - Wiltshire Community Activit
Page 233 and 234:
The Trust is currently reviewing it
Page 235 and 236:
Enhanced Quality Governance Reporti
Page 237 and 238:
The Trust is using its foundation t
Page 239 and 240:
of implementing the programme. Incl
Page 241 and 242:
As part of the corporate back offic
Page 243 and 244:
What patients and service users hav
Page 245 and 246:
3.25.3 Patient Surveys The PICKER I
Page 247 and 248:
3.25.5 Annual Inpatient Survey The
Page 249 and 250:
CHART - Percentage of patients who
Page 251 and 252:
3.28 Working with our partners to s
Page 253 and 254:
3.31 Statement as to disclosures to
Page 255 and 256:
4 REMUNERATION REPORT Information n
Page 257 and 258:
4.5 Remuneration of senior managers
Page 259 and 260:
4.8 Pension Benefits and Remunerati
Page 261 and 262:
The accounting policies for pension
Page 263 and 264:
5 NHS FOUNDATION TRUST CODE OF GOVE
Page 265 and 266:
There is currently a vacancy for th
Page 267 and 268:
5.1.5 Attendance at meetings of the
Page 269 and 270:
In addition, in preparing the Trust
Page 271 and 272:
5.1.11 Council of Governors Meeting
Page 273 and 274:
5.2 Board of Directors 5.2.1 The Bo
Page 275 and 276:
Roger Hill, Non-Executive Director
Page 277 and 278:
Helen Bourner, Director of Business
Page 279 and 280:
5.2.4 Statement about the balance,
Page 281 and 282:
5.2.9 Significant Commitments of th
Page 283 and 284:
5.3.2 The work of the Audit, Risk a
Page 285 and 286:
5.6 Nominations Committee 5.6.1 The
Page 287 and 288:
5.7 Mental Health Act / Mental Capa
Page 289 and 290:
5.8 Membership 5.8.1 Membership The
Page 291 and 292:
The groupings of the members in the
Page 293 and 294:
5.8.8 Membership development propos
Page 295 and 296:
G.1.2 - The Board should clarify in
Page 297 and 298:
and Governors. We have also commenc
Page 299 and 300:
Regulation 1. To sustain compliance
Page 301 and 302:
Audit / confidential enquiry title
Page 303 and 304:
Audit Title Submitted/Required (%)
Page 305 and 306:
No. Audit Title Learning From The P
Page 307 and 308:
No. Audit Title 8. Diabetes Ketoaci
Page 309 and 310:
No. Audit Title Audit Summary/Learn
Page 311 and 312:
No. Audit Title Audit Summary/Learn
Page 313 and 314:
6.3.4 Registration with Care Qualit
Page 315 and 316:
Steering Group, provides a quarterl
Page 317 and 318:
Clostridium Difficile: The goal for
Page 319 and 320:
Priority 2: To reduce harm associat
Page 321 and 322:
Priority 3: To reduce harm associat
Page 323 and 324:
Pressure ulcers Community: The comm
Page 325 and 326:
Safe care of the patient receiving
Page 327 and 328:
CHART - Serious Incidents grouped b
Page 329 and 330:
The three top serious incident caus
Page 331 and 332:
West conference call in August 2011
Page 333 and 334:
Priority 9: To review the clinical
Page 335 and 336:
Priority 12: To undertake nutrition
Page 337 and 338:
• A regular ongoing training prog
Page 339 and 340:
Community: • Q1 Performance April
Page 341 and 342:
The survey results demonstrate that
Page 343 and 344:
6.6 Performance against key nationa
Page 345 and 346:
6.8 Statements from Primary Care Tr
Page 347 and 348:
6.8.4 Wiltshire Primary Care Trust
Page 349 and 350:
6.9 Independent Assurance Report to
Page 351 and 352:
7 SUSTAINABILITY REPORTING 7.1 Stro
Page 353 and 354:
Graphs 3 and 4 show energy consumpt
Page 355 and 356:
Graph 7 - Water consumption in WCHS
Page 357 and 358:
8 EQUALITY REPORTING 8.1 Equality d
Page 359 and 360:
9 STAFF SURVEY REPORT 9.1 Our staff
Page 361 and 362:
It was agreed that we would focus o
Page 363 and 364:
Appraisal rates. The overall rate f
Page 365 and 366:
A quarterly “Voluntary Service Ma
Page 367 and 368:
10 REGULATORY RATINGS REPORT 10.1 M
Page 369 and 370:
10.3.2 Explanation for differences
Page 371 and 372:
12 STATEMENT OF ACCOUNTING OFFICER
Page 373 and 374:
Page 162 of 211
Page 375 and 376:
14.4 The risk and control framework
Page 377 and 378:
Risk Licence to operate (compliance
Page 379 and 380:
The governors and wider stakeholder
Page 381 and 382:
Steps which have been put in place
Page 383 and 384:
14.8 Conclusion I have not identifi
Page 385 and 386:
SHA - Strategic Health Authority SW
Page 387 and 388:
Page 389 and 390:
Page 391 and 392:
Page 393 and 394:
Page 395 and 396:
Page 397 and 398:
Page 399 and 400:
Page 401 and 402:
Page 403 and 404:
Page 405 and 406:
Page 407 and 408:
Page 409 and 410:
Page 411 and 412:
Page 413 and 414:
Page 415 and 416:
Page 417 and 418:
Page 419 and 420:
show all

Annual Report and Accounts - The Great Western Hospital

Create successful ePaper yourself

Delete template?

Save as template?