Annual Report and Accounts - The Great Western Hospital

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5.9 Code of Governance Disclosure Statement The Trust Board has overall responsibility for the administration of sound corporate governance throughout the Trust and recognises the importance of a strong reputation. Monitor, the independent regulator for Foundation Trusts, published the NHS Foundation Trusts Code of Governance. The way in which the Trust applies the principles within the Code of Governance are set out in this report, and the Directors consider that in 2011/12, the Trust has been compliant with the Code with the exception of the following: - A.3.1 – Based on the recommendations of a Joint Nominations Committee comprising Directors and Governors, the Council of Governors rather than the Board determined whether non-executive directors seeking re-appointment were independent in character and judgment and whether there were relationships or circumstances which were likely to affect, or could appear to affect, the director’s judgement. The Council of Governors determined that the non-executive directors were independent, notwithstanding that they had served on the Board of the NHS Foundation Trust for more than six years from the date of their first appointment, the reasons for which are stated elsewhere in this report (section 5.2.3 refers). B.1.7 – Practices and procedures are in place for engagement by Council of Governors with the Board of Directors for those circumstances when there are concerns about the performance of the Board, compliance with the terms of authorisation or other matters related to the general wellbeing of the Trust. Provisions are also included within the Constitution and role descriptions for the Lead and Deputy Lead Governor. The intention is to capture this in one policy document for consideration by the Council of Governor in 2012/13. C.1.5 – The Trust has a Joint Nominations Committee responsible for nominating Non-Executive Directors for appointment and re-appointment. At present there is an equality of membership of Directors and Governors. Therefore in 2011/12, to ensure a majority of governors made nominations, the Joint Nominations Committee met with the Governor Nominations and Remuneration Working Group. Going forward into 2012/13, it has already been supported that the membership of the Joint Nominations Committee, which is in accordance with Constitutional provisions, will be amended to increase the number of Governor members. C.2.2 – One Non-Executive Director is currently in the last year of a four year term. appointments and re-appointments are at intervals of no more than 3 years. All new F.3.9 – The audit committee did not review arrangements by which staff of the NHS foundation trust may raise in confidence concerns about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters. However, the Trust has in place a Whistle Blowing policy which was highlighted to staff by the Senior Independent Director. Furthermore, guidance was issued to governors on how to handle matters referred to them. In addition the Trust has in place a counter fraud policy. Annually the Local Counter Fraud officer undertakes a staff fraud awareness survey. In 2011/12 456 members of staff answered the survey a ten fold increase compared with the previous year. The survey demonstrates that a high proportion (60%) of respondents knew the Trust had a Local Counter Fraud Specialist and how to contact them. The work conducted by the Local Counter Fraud Specialist can also be demonstrated by the increase of referrals and general assistance during 2011/12, which resulted in five investigations taking place. G.1.1 – The Trust should have a public document setting out the Trust’s policy on the involvement of members, patients and the local community at large including a description of the kind of issues it will consult. This is being drafted and will be considered by the Board later in 2012/13. The Trust’s approach is outlined in a number of documents and the intention is to capture this in one policy. Page 83 of 211
G.1.2 – The Board should clarify in writing how the public interests of patients and the local community will be represented, including its approach for addressing the overlap and interface between governors and any local consultative forums already in place. This is being drafted and will be considered by the Board later in 2012/13. Page 84 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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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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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
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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 289 and 290: 5.8 Membership 5.8.1 Membership The
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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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