Annual Report and Accounts - The Great Western Hospital

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The survey results demonstrate that clear guidance needs to be given to both staff and patients. Further actions required: • Provision of medicine reminder card with all discharges via pharmacy • A multidisciplinary meeting including nursing and medical representation to review the process and information sharing of medication on discharge Community: • Q1 Performance April to June 2011: 7.3% - Achieved • Q2 Performance July to September 2011: 21.5% - Not achieved • Q3 Performance October to December 2011: 21% - Not achieved • Q4 Performance January to March 2012: Data not yet available As with the measure for GWH, there is work around information of medication to be undertaken in Community Inpatient areas. The Community Inpatient areas receive their discharge medication in a different way, however the way that this information is shared with patients can be replicated from GWH. Further actions required: • Review of the way medications are given to patients discharged from Community Inpatient areas Priority 18: To ensure patients know who to contact after discharge if they have concerns about their care GWH: • Q1 Performance April to June 2011: 34.5% - Not achieved • Q2 Performance July to September 2011: 21.8% - Achieved • Q3 Performance October to December 2011: 23.20% - Achieved • Q4 Performance January to March 2012: Data not yet available The National Inpatient Survey 2010 showed that 26% of patients were not told who to contact if they were worried after they were discharged. The Unscheduled Care Directorate has led on the discharge policy review and the introduction of discharge leaflets. This links with the work that Pharmacy has been undertaking to improve patient information on discharge. The Unscheduled Care Directorate have facilitated a number of workshops on improving the pathway to discharge Community: • Q1 Performance April to June 2011: 30% - Not achieved • Q2 Performance July to September 2011: 23.7% - Not achieved • Q3 Performance October to December 2011: 25% - Not achieved • Q4 Performance January to March 2012: Data not yet available Community Inpatient areas are managed by the Unscheduled Care Directorate. As the Directorate are leading the work on discharge, it gives an ideal opportunity for good practice to be replicated. Page 130 of 211
6.5 Care Quality Commission (CQC) Inspections There have been a total of 9 external inspections by the CQC and a schedule of work has been developed to monitor progress with the action plans arising following each inspection. Following 8 of those inspections (noting the ninth inspection happening in mid May, the outcome of which is awaited), a CQC judgement of not fully compliant for the following three outcomes at Great Western Hospital site has been made: • Outcome 1 Respecting and Involving people who use services In April 2011, the Trust was judged as none compliant with Outcome 1 due to its inability to demonstrate the provision of adequate and consistent patient privacy and dignity. An action plan was developed and completed by September 2011. In December 2011 a follow up inspection by the CQC deemed the trust as compliant with some improvement actions. • Outcome 4 ( Care & Welfare of people who use services On December 8 th 2011, the CQC specialist inspection for Theatres judged the site as non compliant due to inconsistency of WHO checklist completion. Completion of action plan and subsequent regular internal audits and inspections for assurance has provided clear evidence of compliance and the Trust has declared compliance with Outcomes four as from 30 th April 2012 with the CQC. • Outcome 5 ( Meeting nutritional needs) On December 8 th 2011, the CQC inspectors focussed on hydration and after finding 3 incomplete fluid charts on one ward, judged the site as non compliant. Completion of action plans, a hydration strategy internal review, Productive Ward improvements and subsequent weekly internal audits and inspections has provided clear evidence of compliance and the Trust has declared compliance with Outcomes five as from 30 th April 2012 with the CQC. Other External Reviews A dynamic database system has been created to enable tracking of all external reviews and inspections. This system enables the Trust to track progress, actions and compliance status and is reported to the Patient Safety and Quality Committee. Page 131 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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The Mental Health Act / Mental Capa
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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 and 128: CHART - National Sentinel Stroke Au
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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
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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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