Annual Report and Accounts - The Great Western Hospital

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14 In relation to the use of financial instruments, an indication of the financial risk management objectives and policies of the Trust and the exposure of the entity to price risk, credit risk, liquidity risk and cash flow risk, unless such information is not material for the assessment of the assets, liabilities, financial position and results of the entity are included in the account notes. 15 Disclosures in respect of policy and payment of creditors are included in the notes to the accounts. Page 14 of 211
Business Review / Management Commentary / Operating and Financial Review 3.5 Review of the Trust’s Business The Trust’s Annual Plan submitted to Monitor (the regulator of Foundation Trusts) sets out the organisation’s priorities for delivery during the year. Listed below are some of the important issues which the Trust dealt with 2011/12 and improvements that the Trust has made over the course of the last year. The Trust continues to make progress towards the six strategic objectives which guide the direction of the Trust. Key developments during the year towards achieving each objective are as follows: 1. To provide consistently high quality, safe services which deliver desired patient outcomes and we will perform in the top 25% (upper quartile) of comparable acute trusts in delivering Hospital Standardised Mortality Rates (HSMR), patient satisfaction and staff satisfaction. Quality and safety remain our top priorities as we want patients to be confident they will receive the best care possible, whether they access the Emergency Department at the GWH or are cared for at Warminster Community Hospital or at home. The Trust continues to focus on ensuring that there is a consistently high standard of care provided across all wards and departments to improve patient experience and remove the variability in standards that sometimes exist. During the course of the year the Trust has: • Expanded the Productive Ward Programme to include all Community Hospitals in Wiltshire. The first phase of this work began at Savernake Hospital at the end of January and the programme is designed to ‘buddy’ a community ward with a ward at the GWH to share experience and learning from the wider Productive Ward Initiative which has been in place at the GWH since 2009. Details of the benefits of the Productive Ward are included elsewhere in this report (section 3.22.1 refers). The Trust has also expanded the programme to cover Theatres and will see more nursing time released through improvements in ward and theatre working, time which can be reinvested back into direct patient care. • The Medical Director has introduced a regular safety briefing aimed at Junior Doctors but relevant to all clinical staff featuring important ‘calls to action’ around specific safety issues. The first issue was published in March 2012 and has been well received therefore it will become a regular tool to engage clinical staff on the safety agenda. • Overall our safety performance through the year has been good showing strong improvements in many areas. As evidence, at a meeting of NHS Chief Executives in the South West in January, the Trust and the wider NHS in Swindon was commended as one of the best performing places in the country for infection control, as a result of the significant efforts to tackle Clostridium difficile in particular. • Following three Never Events during the course of the year, the Trust invited Plymouth Hospitals to visit the Trust to share their learning from similar experiences so that safety practices could be strengthened. This work has led to the re-launch of a Safer Surgical Page 15 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: Further Companies Act Disclosures 3
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
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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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The Trust has a wide range of staff
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5.8.6 Membership Strategy To encour
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5.9 Code of Governance Disclosure S
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6 QUALITY REPORTS Part 1 - Statemen
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Part 2 - Priorities for improvement
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6.3.1 Review of services and partic
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The trust chose not to contribute t
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No. Audit Title Reconstruction Audi
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The reports of 273 local clinical a
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No. Audit Title 15. Non Invasive Ve
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No. Audit Title Antibiotic Prescrib
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No. Audit Title 50. NICE CG111 - No
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Great Western Hospitals NHS Foundat
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Part 3 - Other Information 6.4 Over
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GRAPH - Clostridium Difficile WCHS2
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GRAPH - Medicine incidents by type
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Harm from falls WCHS: It was not po
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• Rolling educational programme w
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CHART - Relative risk SW Acute Trus
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Following the Trust’s merge in Ju
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Priority 7: Participation on the Re
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All the guidelines have been dissem
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This has been achieved by: • Mont
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• As a result of complaints and c
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CHART - National Sentinel Stroke Au
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Priority 16: To ensure patients are
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6.5 Care Quality Commission (CQC) I
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6.7 Statement of Directors’ respo
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a Quality Account and the opportuni
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Overall, the Trust has good plans t
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Graph 1 - GWH carbon footprint (ton
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The Trust is working with local bus
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Graph 9 - Total tonnes of waste pro
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The Trust will be working towards a
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Detailed below is a summary of the
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Wiltshire Community Health Services
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providers. Feedback obtained across
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The Musculoskeletal Disorder team a
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10.2.2 Governance risk rating The t
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11 OTHER DISCLOSURES IN PUBLIC INTE
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13 AUDITOR’S OPINION AND CERTIFIC
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14 ANNUAL GOVERNANCE STATEMENT 14.1
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• the key controls to mitigate ag
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14.4.6 Organisation Culture The Tru
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14.5 Review of economy, efficiency
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Process Board Role and Conclusions
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15 GLOSSARY OF TERMS BARS - Blood A
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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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