Annual Report and Accounts - The Great Western Hospital

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3.24 Complaints Handling For the Trust to continue to improve its’ services we need to continue to actively gather, listen and act upon feedback from patients and service users. In seeking feedback we are able to assure ourselves whether the services we are providing meet the needs of those who use them. Where we fall short of the high standards we aspire to, we look to make changes to the way we deliver care. This journey of continual improvement means that we are always looking at ways we can deliver a better service for people now and in the future. Within the Trust there is a dedicated team responsible for leading on all aspects of patient experience, working with the clinical directorates to support improvements and respond to feedback. The Patient Advice and Liaison Service (PALS) is led by the Head of Patient Experience and Director of Nursing and Midwifery. PALS is at the forefront of gaining feedback and being a point of contact for our patients and their carers to seek advice and give their views. The Trust’s strategic objectives incorporate three elements that feed directly into patient experience: - To improve the patient and carer experience of every aspect of the service and care that we deliver. - To ensure that staff are proud to work at GWH and would recommend the Trust as a place to work, or to receive treatment. - To work in partnership with others so that we provide seamless care for patients. The vast majority of patients who use Trust services have a positive experience. They are cared for by caring staff, using the best technology, with treatment by skilled and dedicated professionals. With over 540,000 patient interactions a year, unfortunately there is a small number that are dissatisfied with their care or treatment. Whilst the number is small, the emphasis we place on them is big, so that we can learn how to do things better. A proactive approach is taken to handling any concerns and complaints. The Head of Patient Experience and Director of Nursing and Midwifery liaise with patients who have raised multiple concerns and complaints with the Trust. These patients are invited into the Trust to tell us about their experience and give us the opportunity to discuss the work that we are doing. To provide a more visible service to patients and the public, the PALS office moved into a refurbished and extended office in January 2012 situated close to the main entrance to the Great Western Hospital (GWH). This extension created two meeting rooms, one informal room and one formal room for holding complaint meetings. The Trust was successful in a One Swindon bid, a scheme to raise the visibility of the Police within public services and encourage joint working. The scheme contributed towards the cost of the PALS extension and the Police are actively using PALS as a base when they are on site. Demonstrating how patient experience is a key focus for the senior management of the Trust, during 2011/12 the Patient Experience Report increased to monthly instead of quarterly. This increase in reporting gives the Directorate management and Executive Team a more frequent measure of patient satisfaction and enables monitoring of service improvements. Since the end of the year a ’patient story’ has been included detailing the experience of an individual patient from the previous month. This has been put in place to allow the Executive to look beyond the numbers and the written feedback to truly reflect on individual experience – the good and the bad. This is providing a useful way to share lessons learned in one directorate across the rest of the organisation. Page 29 of 211
As part of the corporate back office, PALS is undergoing a restructure which will be completed during quarter one 2012/13. The restructure gives an opportunity to review the process of informal and formal complaint management, with a clear separation between the two. A clinical post is being introduced to oversee the formal complaint process which will strengthen the level of clinical understanding within PALS with the aim of improving response times. As part of the restructure, a training specification for PALS staff is also being introduced. 3.24.1 Formal complaints During 2011/12, 444 formal complaints were made to the Trust compared with 242 during 2010/11. The number of formal complaints received by the Trust represents 0.08% of the total number of patients seen, treated or admitted during 2011/12. When the Trust merged with Wiltshire Community Health Services in June 2011, PALS at GWH became the point of contact for patients and their carers with queries or concerns from across the Wiltshire Services. This in turn has resulted in an increase in the number of contacts with the PALS. Nationally there is an increase in the number of complaints being made to Trusts. The Trust uses complaints as a resource and opportunity to review services and to identify areas for improvement. A lot of work has been undertaken across the organisation to raise the patient and public awareness of PALS and the importance of gathering feedback. This is also reflected in the increase of contacts with the service as the Trust embraces the culture of seeking continuous patient feedback. The graph below compares the number of Formal Complaints received during 2011/12 with 2010/11, 2009/10 and 2008/09. Chart - Number of Formal Complaints received 140 120 100 80 60 40 20 0 59 51 43 66 65 44 54 47 58 49 88 92 108 115 129 2008/09 Qtr 2 2008/09 Qtr 3 2008/09 Qtr 4 2009/10 Qtr 1 2009/10 Qtr 2 2009/10 Qtr 3 2009/10 Qtr 4 2010/11 Qtr 1 2010/11 Qtr 2 2010/11 Qtr 3 2010/11 Qtr 4 2011/12 Qtr 1 2011/12 Qtr2 2011/12 Qtr3 2011/12 Qtr 4 Number of Formal Complaints Page 30 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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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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Page 189 and 190: Great Western Hospitals NHS Foundat
Page 209: Great Western Hospitals NHS Foundat
Page 214: Great Western Hospitals NHS Foundat
Page 217 and 218: 1 CHAIR AND CHIEF EXECUTIVE’S REP
Page 219 and 220: 2 OUR TRUST 2.1 Vision - Your healt
Page 221 and 222: 3 DIRECTOR’S REPORT General Compa
Page 223 and 224: 3.3.2 The Brunel Treatment Centre O
Page 225 and 226: 14 In relation to the use of financ
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Page 229 and 230: organisations to adapt to these cha
Page 231 and 232: TABLE - Wiltshire Community Activit
Page 233 and 234: The Trust is currently reviewing it
Page 235 and 236: Enhanced Quality Governance Reporti
Page 237 and 238: The Trust is using its foundation t
Page 239: of implementing the programme. Incl
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Page 245 and 246: 3.25.3 Patient Surveys The PICKER I
Page 247 and 248: 3.25.5 Annual Inpatient Survey The
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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 261 and 262: The accounting policies for pension
Page 263 and 264: 5 NHS FOUNDATION TRUST CODE OF GOVE
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Page 267 and 268: 5.1.5 Attendance at meetings of the
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Page 271 and 272: 5.1.11 Council of Governors Meeting
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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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Annual Report and Accounts - The Great Western Hospital

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