Annual Report and Accounts - The Great Western Hospital

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Enhanced Quality Governance Reporting Quality governance is combination of structures and processes at and below Board level to lead on trust-wide quality performance including: • ensuring required standards are achieved; • investigating and taking action on sub-standard performance; • planning and driving continuous improvement; • identifying, sharing and ensuring delivery of best-practice; and • identifying and managing risks to quality of care. Arrangements in place to ensure quality governance and quality are discussed in more detail within the annual governance statement (section14 refers) and the quality report (section 6 refers). 3.15 Monitor’s Quality Governance Framework The Trust has had regard to Monitor's quality governance framework in arriving at its overall evaluation of the organisation’s performance, internal control and board assurance framework. In June 2011 and again in September 2011, the Trust undertook an evaluation of its strategy; capabilities and culture; processes and structure and measurements mapping them against Monitor’s Quality Governance Framework. In addition, the Trust commissioned an independent audit which provided substantial assurance regarding the Trust’s quality governance arrangements. The Trust has not developed one specific action plan to improve the governance of quality. However, throughout the Trust there are plans or ongoing processes which contribute to its improvement. Examples of this include: - • Development of the Trust’s business strategy with particular emphasis on quality. • Monthly reporting to the Board on risks and potential risks to quality, with action plans in place to address any gaps in assurance. • Ongoing Board development with the Institute for Innovation and Improvement and refreshment of the Board to ensure that the Board has the necessary skills and qualities to manage the Trust and deliver the quality agenda. • Promotion of a quality focused culture throughout the Trust evidenced by the roll of staff values and improved communication and feedback mechanisms. Quality is considered in developing policies and procedures for the Trust with consideration given to the impact on clinical effectiveness, patient experience and the quality of care. • There are clear processes for escalating quality performance issues to the board. These are documented, with agreed rules determining which issues should be escalated. These rules cover, amongst other issues, escalation of serious untoward incidents and complaints. Robust action plans are put in place to address quality performance issues. • Quality information is analysed and challenged in a number or areas. The board reviews a monthly ‘dashboard’ of the most important metrics. Page 24 of 211
Patient care 3.16 Development of services to improve patent care We treat thousands of patients every year as follows: - TABLE – Patients seen, treated or admitted 2007/08 – 2011/12 2007/08 2008/09 2009/10 2010/11 2011/12 Variance from 2010/11 New outpatients 87,441 90,852 94,587 96,456 137504 5.4 Follow up appointments 179,466 195,846 198,244 212,887 263066 14.3 Day cases 26,102 28,508 28,053 27,813 27320 -1.9 Emergency inpatients 34,075 36,658 39,202 35,210 35804 1.6 Elective inpatients 7,438 7,345 7,004 7,269 6723 -7.8 Emergency Department attendances 60,583 62,628 66,262 68,618 70731 3.1 The table above is for GWH acute activity only. 2008/09 onwards includes GUM/HIV, A&E, Anticoagulation in outpatient figures. 2011/12 outpatient activity includes former Swindon PCT therapies activity. Table – Patients seen, treated or admitted 2011/12 by former WCHS Community Services 2011/12 Minor Injuries Unit 46,507 Admitted Patients 7,445 Community contacts including outpatient 803,545 Page 25 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 and 14: Further Companies Act Disclosures 3
Page 15 and 16: Business Review / Management Commen
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: 3.13 Contractual arrangements The T
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
Page 65 and 66: Lyn Hill-Tout, Chief Executive (unt
Page 67 and 68: 5.2.3 Length of appointments of Non
Page 69 and 70: 5.2.6 Attendance at meetings of the
Page 71 and 72: 5.3 Audit Committee 5.3.1 The Audit
Page 73 and 74: 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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Annual Report and Accounts - The Great Western Hospital

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