Annual Report and Accounts - The Great Western Hospital

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Community: • Q1 Performance April to June 2011: 31% - Achieved • Q2 Performance July to September 2011: 31% - Achieved • Q3 Performance October to December 2011: 4% - Achieved • Q4 Performance January to March 2012: Data not yet available Satisfaction surveys are given to all patients upon discharge from the Trust’s Community Inpatient areas. Community inpatient services are provided from four wards across three sites, Longleat Ward - Warminster Hospital, Aylesbury Ward - Savernake Hospital, and two wards at Chippenham Community Hospital, Cedar Ward and Beech Ward which is a Stroke rehabilitation Unit. There are currently low numbers of participants in the surveys. The Community Inpatient Survey will be incorporated within the patient survey tender in quarter one 2012/13. The Community Inpatient Survey results demonstrate that the Community Inpatient areas are consistently achieving this measure. Priority 15: To ensure staff are available to discuss care concerns with patients and their carers GWH: • Q1 Performance April to June 2011: 40.7% - Achieved • Q2 Performance July to September 2011: 54.5% - Achieved • Q3 Performance October to December 2011: 61.6% - Not achieved • Q4 Performance January to March 2012: Data not yet available The National Inpatient Survey 2010 showed that 59% of patients could not always find a member of staff to discuss concerns with. During quarters one and two 2011/12, there has been an increase in patient satisfaction in this measure, which decreased in quarter three. Posters showing photographs of the Ward Managers and Matrons have been displayed during March 2012, to inform patients of the clinical managers in the ward should they wish to speak with some one. The introduction of bedside handovers will also increase the availability of nursing staff to speak with patients about their care. Community: • Q1 Performance April to June 2011: 10.1% - Not achieved • Q2 Performance July to September 2011: 6.2% - Not Achieved • Q3 Performance October to December 2011: 9% - Not achieved • Q4 Performance January to March 2012: Data not yet available The results of the Community Inpatient Survey show that there is further work required to improve patient satisfaction in this area. Further actions required: • Roll out of ward managers surgeries to encourage patients and their carers to ask questions and query care whilst on the ward • Bedside handovers to keep patients aware of their care and to be informed of any tests or procedures to be carried out during that shift • Posters showing photographs of the Ward Manager and Matron to be displayed Page 128 of 211
Priority 16: To ensure patients are given sufficient privacy when discussing care and concerns GWH: • Q1 Performance April to June 2011: 27.4% - Achieved • Q2 Performance July to September 2011: 24.8% - Achieved • Q3 Performance October to December 2011: 29.1% - Achieved • Q4 Performance January to March 2012: Data not yet available The National Inpatient Survey 2010 showed that 31% of patients felt that there was not enough privacy when discussing their care or treatment. The quarterly survey results for 2011/12 show an increase in patient satisfaction in this area. A matron within the Planned Care Directorate carried out a privacy audit in November 2011 to collect information on the different ways that privacy notices are used when discussions are taking place around the bedside. As part of the bedside handover, confidential information about patients is discussed away from the bedside. Safety briefings have also been introduced to share information with staff on handover and are carried out away from the bedside. Further actions required: • Standardised privacy notices to be rolled out to wards as part of the hygiene module of the Productive Ward Community: • Q1 Performance April to June 2011: 6.3% - Achieved • Q2 Performance July to September 2011: 3.2% - Achieved • Q3 Performance October to December 2011: 1% - Achieved • Q4 Performance January to March 2012: Data not yet available There has been an improvement of patient satisfaction in this area during 2011/12. Further actions required: • Audit of curtain peg and privacy notice use across community inpatient areas with a view to introducing the Trust wide standardised privacy notices Priority 17: To improve upon the information given to patients on medication and it side effects GWH: • Q1 Performance April to June 2011: 30.8% - Achieved • Q2 Performance July to September 2011: 42.9% - Achieved • Q3 Performance October to December 2011: 65% - Not achieved • Q4 Performance January to March 2012: Data not yet available There are a number of ways that side effect information could be provided, and a number of developments have been made over the last year by the Pharmacy department to enable this information to be given to patients. These include, information leaflets included with all discharge medicines, patient information available via the internet and a patient medicines information helpline which is publicised via Outpatients. Page 129 of 211
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Great Western Hospitals NHS Foundat
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CONTENTS 1 Chair and Chief Executiv
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The Great Western Hospital became a
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Underpinning this, our values are t
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3.2 Principal activities of the Tru
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Further Companies Act Disclosures 3
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Business Review / Management Commen
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3. To ensure that staff are proud t
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6. To work in partnership with othe
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With funding received from the Depa
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3.13 Contractual arrangements The T
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Patient care 3.16 Development of se
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3.20 New or significantly revised s
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3.24 Complaints Handling For the Tr
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The Trust actively responds to feed
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3.25 Using patient experience to dr
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The table below shows the CQUIN res
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Action plans based on the Quarterly
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3.27 Development of services with o
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3.29 Health and Overview Scrutiny C
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3.32.5 Interests held by Directors
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4.3 Attendance at meetings of the R
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4.7 Board of Directors’ employmen
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Remuneration Name Title Salary (Ban
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4.8.4 Additional disclosures The Tr
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5.1.2 Elected Governors - Public Co
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5.1.4 Nominated Governors Name Nomi
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5.1.6 Lead and Deputy Lead Governor
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“Eyes and Ears” - An initiative
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5.1.12 Nominations and Remuneration
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Rowland Cobbold, Non-Executive Dire
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Lyn Hill-Tout, Chief Executive (unt
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5.2.3 Length of appointments of Non
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5.2.6 Attendance at meetings of the
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5.3 Audit Committee 5.3.1 The Audit
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5.4 Directors’ responsibility for
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Note: Angela Gillibrand and Rowland
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Page 79 and 80: The Trust has a wide range of staff
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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 and 100: No. Audit Title Antibiotic Prescrib
Page 101 and 102: No. Audit Title 50. NICE CG111 - No
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: CHART - National Sentinel Stroke Au
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
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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: Great Western Hospitals NHS Foundat
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1 CHAIR AND CHIEF EXECUTIVE’S REP
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2 OUR TRUST 2.1 Vision - Your healt
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3 DIRECTOR’S REPORT General Compa
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3.3.2 The Brunel Treatment Centre O
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14 In relation to the use of financ
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Checklist, a World Health Organisat
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organisations to adapt to these cha
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TABLE - Wiltshire Community Activit
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The Trust is currently reviewing it
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Enhanced Quality Governance Reporti
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The Trust is using its foundation t
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of implementing the programme. Incl
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As part of the corporate back offic
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What patients and service users hav
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3.25.3 Patient Surveys The PICKER I
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3.25.5 Annual Inpatient Survey The
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CHART - Percentage of patients who
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3.28 Working with our partners to s
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3.31 Statement as to disclosures to
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4 REMUNERATION REPORT Information n
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4.5 Remuneration of senior managers
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4.8 Pension Benefits and Remunerati
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The accounting policies for pension
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5 NHS FOUNDATION TRUST CODE OF GOVE
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There is currently a vacancy for th
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5.1.5 Attendance at meetings of the
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In addition, in preparing the Trust
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5.1.11 Council of Governors Meeting
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5.2 Board of Directors 5.2.1 The Bo
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Roger Hill, Non-Executive Director
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Helen Bourner, Director of Business
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5.2.4 Statement about the balance,
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5.2.9 Significant Commitments of th
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5.3.2 The work of the Audit, Risk a
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5.6 Nominations Committee 5.6.1 The
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5.7 Mental Health Act / Mental Capa
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5.8 Membership 5.8.1 Membership The
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The groupings of the members in the
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5.8.8 Membership development propos
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G.1.2 - The Board should clarify in
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and Governors. We have also commenc
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Regulation 1. To sustain compliance
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Audit / confidential enquiry title
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Audit Title Submitted/Required (%)
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No. Audit Title Learning From The P
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No. Audit Title 8. Diabetes Ketoaci
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No. Audit Title Audit Summary/Learn
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No. Audit Title Audit Summary/Learn
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6.3.4 Registration with Care Qualit
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Steering Group, provides a quarterl
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Clostridium Difficile: The goal for
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Priority 2: To reduce harm associat
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Priority 3: To reduce harm associat
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Pressure ulcers Community: The comm
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Safe care of the patient receiving
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CHART - Serious Incidents grouped b
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The three top serious incident caus
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West conference call in August 2011
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Priority 9: To review the clinical
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Priority 12: To undertake nutrition
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• A regular ongoing training prog
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Community: • Q1 Performance April
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The survey results demonstrate that
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6.6 Performance against key nationa
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6.8 Statements from Primary Care Tr
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6.8.4 Wiltshire Primary Care Trust
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6.9 Independent Assurance Report to
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7 SUSTAINABILITY REPORTING 7.1 Stro
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Graphs 3 and 4 show energy consumpt
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Graph 7 - Water consumption in WCHS
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8 EQUALITY REPORTING 8.1 Equality d
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9 STAFF SURVEY REPORT 9.1 Our staff
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It was agreed that we would focus o
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Appraisal rates. The overall rate f
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A quarterly “Voluntary Service Ma
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10 REGULATORY RATINGS REPORT 10.1 M
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10.3.2 Explanation for differences
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12 STATEMENT OF ACCOUNTING OFFICER
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14.4 The risk and control framework
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Risk Licence to operate (compliance
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The governors and wider stakeholder
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Steps which have been put in place
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14.8 Conclusion I have not identifi
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SHA - Strategic Health Authority SW
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Annual Report and Accounts - The Great Western Hospital

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