Annual Report and Accounts - The Great Western Hospital

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Note: Angela Gillibrand and Rowland Cobbold are Non-Executive Directors appointed to the Committee by the Chairman Bruce Laurie also a Non-Executive Director and Godfrey Fowler, Harry Dale and Marcus Galea are Governors appointed by the Council of Governors. The Chair of the Committee is Bruce Laurie, Chairman of the Trust. Note that in addition to the Joint Nominations Committee, there is a Remuneration Committee authorised by the Trust Board to oversee a formal, rigorous and transparent procedure for the appointment of the Chief Executive and other Board Executive Directors and to keep under review the composition size and structure of the Executive, leading on succession planning, appointing candidates to Board level positions. The Remuneration Committee reviews senior manager (Executive Director) remuneration and has delegated authority for agreeing any annual pay review for these staff only. Page 75 of 211
5.7 Mental Health Act / Mental Capacity Act Committee 5.7.1 The Mental Health Act / Mental Capacity Act Committee Under the terms of the Mental Health Act 1983, (MHA) the Trust has a key responsibility for looking after patients who come to the hospital with problems associated with their mental health and to ensure that that the requirements of the Act are followed. The Trust must: • ensure that patients are detained only as the MHA allows; • ensure that patients’ treatment and care accords fully with the provision of the Act; • patients are fully informed of, and supported in, exercising their rights; • patients’ cases are dealt with in line with other relevant statutory legislation including the Mental Capacity Act 2005, Human Rights Act 1998, The Race Relations Act, Disability Discrimination Act 1995 or Data Protection Act 1998. Membership of the Mental Health Act and Mental Capacity Act Committee • Non-Executive Directors x two • Director of Nursing - Executive Lead for Mental Health Services • Deputy Director of Nursing – Trust Lead for Mental Health Services • Mental Health Act Administrator • Representatives from the Child and Adolescent Mental Health Service (CAMHS) x three (General Manager/Clinician/Nurse) • Senior Representative from the Adult Mental Health Services (AWP) • Senior Representative from Older People’s Mental Health Services (AWP) • Senior Nurse/Matron (Great Western Hospital) • Representative from Swindon Primary Care Trust. 5.7.2 Meetings during 2010/11 and attendance The Mental Health Act / Mental Capacity Act Committee members Jun 2011 Sep 2011 Dec 2011 Cancelled Mar 2012 Bruce Laurie (Chair) Chairman of the Trust √ √ √ Rowland Cobbold (Deputy Non Executive Director x √ √ Chair) Sue Rowley Director of Nursing and Midwifery x √ √ Carole Crocker Deputy Director of Nursing √ Left the Trust Joy Gobey Mental Health Act Administrator √ √ √ Teresa Harding Joanne Smith, Senior Nurse Paediatrics - deputy General Manager, Women and Children’s’ Department x x √ Joanne Smith Dick Eyre Child Psychiatrist x √ √ Attendance as either / both with Amanda Cadder Amanda Cadder Attendance as either/both with Dick Eyre Nurse Manager x x x Page 76 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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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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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 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
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
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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
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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
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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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Page 301 and 302: Audit / confidential enquiry title
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Page 305 and 306: No. Audit Title Learning From The P
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Page 313 and 314: 6.3.4 Registration with Care Qualit
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Page 327 and 328: CHART - Serious Incidents grouped b
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Page 333 and 334: Priority 9: To review the clinical
Page 335 and 336: 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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