Annual Report and Accounts - The Great Western Hospital

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The Great Western Hospital became a designated Trauma Unit in two regional Trauma Networks in April 2012. Due to its geographical location, the Great Western Hospital is part of both the Severn Network to the West and the Thames Valley Network to the North-East. This is a commendable achievement due to the hard work of dedicated staff. With a larger organisation, we are using our experience of rolling out the Productive Ward Programme at the GWH to implement the same initiative in the community hospitals. The programme is designed to release more nursing time to spend on direct patient care and Wiltshire residents will start to see the benefits of our experience in this area during 2012/13. Our staff, who are at the core of the Trust, have also shared their views on what it is like to work within the Trust via the annual independent staff survey. The results, published in March, place the Trust in the top five Trusts in the South West in terms of overall scores. The Trust was placed in the top 20% nationally on many of the key measures and generally our staff are engaged. These results are important not only for staff, but also for patients as more engaged staff means better patient care. We will be building on these results in the year ahead and have identified four priorities for focus to deliver improvements. The year has also been challenging. The expanded programme of unannounced inspections by the Care Quality Commission (CQC) has been felt across the Trust. During the course of the year there several inspections looking at different aspects of care including dignity, nutrition and hydration and theatres. One of the inspections resulted in moderate concerns. Action plans have been developed with the concerns raised now addressed. Plans to manage any remaining issues are being rolled out. One area that is already being managed is the removal of a number of the Extra Bed Spaces in use on some wards. These are additional regular beds intended for use when demand from patients is high. The Trust has recognised that a number of these beds have compromised patient dignity on occasions and we are taking proactive steps to remove them and reduce their use. From a financial perspective the Trust ended a difficult financial year with £0.5m surplus. The challenges going forward will grow, so it is vital we maintain a strong financial discipline. This is particularly important when looked at in the context of falling demand for some services currently provided in a hospital environment. With fewer patients comes less money to invest in services. The Trust therefore needs to be flexible in ensuring we have the beds, staff and resources in the right areas for the demand we are experiencing. Further information on the Trust’s accounts is provided in the annual accounts at the back of this annual report. We continue to work with our Governors to deliver the aspirations of our 12,000 members and have valued their input in shaping our priorities. Governors have contributed to the workings of the Trust by adding valuable feedback and helping us to focus on improvements in areas such as patient experience. The Trust hosted a successful Open Day in September, with many staff from across the Trust giving up their time to showcase their work. Staff hosted behind the scenes tours of different areas of the hospital and a number of partner agencies were represented at the event including Wiltshire Fire and Rescue, Wiltshire Air Ambulance, Wiltshire Involvement Network, Swindon LINk and Prospect Hospice. A total of 50 people (staff and public) safely abseiled off the hospital building with the money raised going to the Trust’s Charitable Fund. We are very grateful for the efforts our 5,500 staff and volunteers who work with us everyday to save and change lives. Despite the challenges and difficult times ahead, we know we are better placed to meet them because of their hard work, professionalism and dedication to the Trust. Page 7 of 211
2 OUR TRUST 2.1 Vision - Your health our passion “We will provide healthcare services that delight patients and satisfy commissioners by meeting, or exceeding, all local and national standards and providing convenient, local services so that people enjoy the best state of health and will have access to first class services when they need them.” A key theme of the vision has been for the Trust to provide ‘healthcare services’ and not solely acute hospital services. Towards achieving the 2015 vision, in June 2011 the Trust took over the running of a range of community health services and community maternity services across Wiltshire and surrounding areas, which were previously provided by Wiltshire Community Health Services (WCHS). This merger is a key step towards achieving our vision as we are now working even more closely with key local partners including the Local Authority, GPs and the third sector to deliver better care, closer to home. 2.2 Our aims and values To achieve our Vision we have the following aims, also known as strategic objectives: - 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. 2. To improve the patient and carer experience of every aspect of the service and care that we deliver. 3. To ensure that staff are proud to work for the Trust and would recommend the Trust as a place to work and to receive treatment. 4. To secure the long term financial health of the Trust. 5. To adopt new approaches and innovate to promote health and improve services as healthcare changes whilst continuing to become even more efficient. 6. To work in partnership with others so that we provide seamless care for patients, more systematically identifying and supporting those individuals at most risk of ill health and delivering closer to home in rural areas. Page 8 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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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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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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Page 173 and 174: 15 GLOSSARY OF TERMS BARS - Blood A
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Page 177 and 178: Great Western Hospitals NHS Foundat
Page 209: Great Western Hospitals NHS Foundat
Page 214: Great Western Hospitals NHS Foundat
Page 217: 1 CHAIR AND CHIEF EXECUTIVE’S REP
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Page 255 and 256: 4 REMUNERATION REPORT Information n
Page 257 and 258: 4.5 Remuneration of senior managers
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Page 263 and 264: 5 NHS FOUNDATION TRUST CODE OF GOVE
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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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