Annual Report and Accounts - The Great Western Hospital

The governors and wider stakeholders are actively involved in the development of the Trust’s
Business Strategy for future years. During 2012/13 there will be further consultations and workshops
with stakeholders to ensure that the Trust’s strategy going forward matches the needs and wishes of
the local community and that there is a full understanding of the risks, threats and opportunities facing
the Trust in the years ahead.
14.4.9 Quality Governance Arrangements
During the 2011/12 financial year, the Trust remained at level 2 for the National Health Service
Litigation Authority (NHSLA) Risk Management Standards for Acute Trusts and was level 2 for
Clinical Negligence Scheme for Trusts (CNST) Risk Management Standards for maternity following
the integration of community services into the Trust.
During 2011/12 revised arrangements were put in place to ensure that there is corporate governance
overview of all policies and Trust wide procedural documents. As part of the revised requirements,
authors are required to carry out an equality impact assessment and a quality impact assessment of
the reviewed document to ensure that any issues of concern relating to equality and quality are
highlighted and addressed.
14.4.10 Internal CQC Compliance Assessment arrangements
Internal processes for assessing compliance against the CQC regulations are led by the Clinical
Standards Group which meets on a monthly basis. The compliance judgement is informed by the
CQCs Quality and Risk Profile and other accessible sources of intelligence. Evidence supporting
compliance is captured on the Trust’s Provider Compliance Assessment Forms which are saved and
managed centrally by the Quality Team. Gaps in compliance inform the Patient Safety and Quality
Committee and actions plans are developed and monitored to ensure improvements are progressed.
Risks identified from the internal compliance assessment and risks arising from within the
directorates, inform the relevant risk registers and are linked to the CQC outcomes.
The Patient Safety and Quality Committee reports to the Executive Committee and Trust Board
monthly on the Trust’s regulatory compliance status.
The foundation trust is not fully compliant with the registration requirements of the Care Quality
Commission.
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 are complied with. This
includes ensuring that deductions from salary, employer’s contributions and payments into 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.
Control measures are in place to ensure that all the organisation’s obligations under equality,
diversity and human rights legislation are complied with.
The foundation trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in
place in accordance with emergency preparedness and civil contingency requirements, as based on
UKCIP 2009 weather projects, to ensure that this organisation’s obligations under the Climate
Change Act and the Adaptation Reporting requirements are complied with.
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