Annual Report and Accounts - The Great Western Hospital

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The table below shows the CQUIN results gathered through the internal surveys. TABLE - Community Services Quality Account results on patient experience Indicator Wanted to be more involved with decisions about care WCHS Could not always find staff to discuss concerns with. WCHS Not enough privacy when discussing care or treatment. WCHS Side effects of medication not fully explained WCHS Not told who to contact after discharge if worried WCHS Regulator Target 2011/12 Quarter 1 Quarter 2 Quarter 3 Quarter 4 QA, PCT, CQUIN
3.25.5 Annual Inpatient Survey The Annual Inpatient Survey was sent to a sample of patients who were admitted in June, July or August 2011. The results of this survey are used to inform the quarter two update of the PICKER Action Plan and are used by the CQC to collate a benchmarking report of Acute Trusts which is due to be published in May 2012. The Trust response rate for the Annual Inpatient Survey was 53.4%, in comparison with the PICKER average of 49.6%. The Trust made significant improvements in comparison with the 2010 Inpatient Survey in four areas and scored significantly better than average on eight questions. The graphs below show the areas of significant improvement in the 2011 Annual Inpatient Survey and the areas significantly better than the PICKER average. CHART - Areas of significant improvement 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 65% 55% Discharge: Not fully told danger signs to look for 25% 19% Discharge: Did not receive copies of letters sent between hospotal doctors and GP 85% 80% Overall: Not asked to give views on quality of care 9% 5% Overall: Wanted to complain about care received 2010 2011 CHART - Areas significantly better than PICKER average 70% 60% 50% 40% 30% 20% 10% 0% 26% 21% 20% 12% 2% 5% 10% 30% 13% 6% 63% 57% 20% 16% A&E Department: Patients in more than Patients using bath or Not offered a choice of Waited 4 hours or one ward sharing shower area who food more for admission to sleeping area with the shared it with the a bed on a ward opposite sex opposite sex 19% 34% Trust Average Page 36 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 195 and 196: 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
Page 227 and 228: Checklist, a World Health Organisat
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 and 240: of implementing the programme. Incl
Page 241 and 242: As part of the corporate back offic
Page 243 and 244: What patients and service users hav
Page 245: 3.25.3 Patient Surveys The PICKER I
Page 249 and 250: CHART - Percentage of patients who
Page 251 and 252: 3.28 Working with our partners to s
Page 253 and 254: 3.31 Statement as to disclosures to
Page 255 and 256: 4 REMUNERATION REPORT Information n
Page 257 and 258: 4.5 Remuneration of senior managers
Page 259 and 260: 4.8 Pension Benefits and Remunerati
Page 261 and 262: The accounting policies for pension
Page 263 and 264: 5 NHS FOUNDATION TRUST CODE OF GOVE
Page 265 and 266: There is currently a vacancy for th
Page 267 and 268: 5.1.5 Attendance at meetings of the
Page 269 and 270: In addition, in preparing the Trust
Page 271 and 272: 5.1.11 Council of Governors Meeting
Page 273 and 274: 5.2 Board of Directors 5.2.1 The Bo
Page 275 and 276: Roger Hill, Non-Executive Director
Page 277 and 278: Helen Bourner, Director of Business
Page 279 and 280: 5.2.4 Statement about the balance,
Page 281 and 282: 5.2.9 Significant Commitments of th
Page 283 and 284: 5.3.2 The work of the Audit, Risk a
Page 285 and 286: 5.6 Nominations Committee 5.6.1 The
Page 287 and 288: 5.7 Mental Health Act / Mental Capa
Page 289 and 290: 5.8 Membership 5.8.1 Membership The
Page 291 and 292: The groupings of the members in the
Page 293 and 294: 5.8.8 Membership development propos
Page 295 and 296: 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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