Annual Report and Accounts - The Great Western Hospital

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6.3.1 Review of services and participation in clinical audits and national confidential enquiries During 2011/12 42 national clinical audits and 4 national confidential enquiries covered NHS services that Great Western Hospitals NHS Foundation Trust provides. During 2011/12 Great Western Hospitals NHS Foundation Trust participated in 86% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that Great Western Hospitals NHS Foundation Trust was eligible to participate in during 2011/12 and those that Great Western Hospitals NHS Foundation Trust participated in are as follows: - Audit / confidential enquiry title Eligible Participated Peri-and Neo-natal Perinatal mortality (MBRRACE-UK) Yes No Neonatal intensive and special care (NNAP) Yes Yes Children Paediatric pneumonia (British Thoracic Society) Yes Yes Paediatric asthma (British Thoracic Society) Yes Yes Pain management (College of Emergency Medicine) Yes Yes Childhood epilepsy (RCPH National Childhood Epilepsy Audit) Yes Yes Paediatric intensive care (PICANet) No NA Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit) No NA Diabetes (RCPH National Paediatric Diabetes Audit) Yes Yes Acute care Emergency use of oxygen (British Thoracic Society) Yes Yes Adult community acquired pneumonia (British Thoracic Society) Yes Yes Non invasive ventilation -adults (British Thoracic Society) Yes Yes Pleural procedures (British Thoracic Society) Yes Yes Cardiac arrest (National Cardiac Arrest Audit) Yes No Severe sepsis & septic shock (College of Emergency Medicine) Yes No Adult critical care (ICNARC CMPD) Yes Yes Potential donor audit (NHS Blood & Transplant) Yes Yes Seizure management (National Audit of Seizure Management) Yes No Long term conditions Diabetes (National Adult Diabetes Audit) Yes No Heavy menstrual bleeding (RCOG National Audit of HMB) Yes Yes Chronic pain (National Pain Audit) Yes Yes Ulcerative colitis & Crohn's disease (UK IBD Audit) Yes Yes Parkinson's disease (National Parkinson's Audit) Yes Yes Adult asthma (British Thoracic Society) Yes Yes Bronchiectasis (British Thoracic Society) Yes No Page 89 of 211
Audit / confidential enquiry title Eligible Participated Elective procedures Hip, knee and ankle replacements (National Joint Registry) Yes Yes Elective surgery (National PROMs Programme) Yes Yes Intra-thoracic transplantation (NHSBT UK Transplant Registry) No NA Liver transplantation (NHSBT UK Transplant Registry) No NA Coronary angioplasty (NICOR Adult cardiac interventions audit) Yes Yes Peripheral vascular surgery (VSGBI Vascular Surgery Database) Yes Yes Carotid interventions (Carotid Intervention Audit) Yes Yes CABG and valvular surgery (Adult cardiac surgery audit) No NA Cardiovascular disease Acute Myocardial Infarction & other ACS (MINAP) Yes Yes Heart failure (Heart Failure Audit) Yes Yes Acute stroke (SINAP) Yes Yes Cardiac arrhythmia (Cardiac Rhythm Management Audit) Yes Yes Renal disease * Renal replacement therapy (Renal Registry) No NA Renal transplantation (NHSBT UK Transplant Registry) No NA Cancer Lung cancer (National Lung Cancer Audit) Yes Yes Bowel cancer (National Bowel Cancer Audit Programme) Yes Yes Head & neck cancer (DAHNO)* Yes Yes Oesophago-gastric cancer (National O-G Cancer Audit) Yes Yes Trauma Hip fracture (National Hip Fracture Database) Yes Yes Severe trauma (Trauma Audit & Research Network) Yes Partly Psychological conditions Prescribing in mental health services (POMH) No NA Schizophrenia (National Schizophrenia Audit) No NA Blood transfusion Bedside transfusion (National Comparative Audit of Blood Transfusion) Medical use of blood (National Comparative Audit of Blood Transfusion) Yes Yes Yes Yes Health promotion Risk factors (National Health Promotion in Hospitals Audit) Yes No End of life Care of dying in hospital (NCDAH) Yes Yes National Confidential Enquiries into Patient Outcome & Death Cardiac arrest Yes Yes GWHFT is not currently participating in the National Cardiac Arrest Audit project; however the Trust has subscribed and made arrangements to participate in the next round of the National Audit. Page 90 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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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
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
Page 297 and 298: and Governors. We have also commenc
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Page 303 and 304: Audit Title Submitted/Required (%)
Page 305 and 306: No. Audit Title Learning From The P
Page 307 and 308: No. Audit Title 8. Diabetes Ketoaci
Page 309 and 310: No. Audit Title Audit Summary/Learn
Page 311 and 312: No. Audit Title Audit Summary/Learn
Page 313 and 314: 6.3.4 Registration with Care Qualit
Page 315 and 316: Steering Group, provides a quarterl
Page 317 and 318: Clostridium Difficile: The goal for
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Page 321 and 322: Priority 3: To reduce harm associat
Page 323 and 324: Pressure ulcers Community: The comm
Page 325 and 326: Safe care of the patient receiving
Page 327 and 328: CHART - Serious Incidents grouped b
Page 329 and 330: The three top serious incident caus
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Page 333 and 334: Priority 9: To review the clinical
Page 335 and 336: Priority 12: To undertake nutrition
Page 337 and 338: • A regular ongoing training prog
Page 339 and 340: Community: • Q1 Performance April
Page 341 and 342: The survey results demonstrate that
Page 343 and 344: 6.6 Performance against key nationa
Page 345 and 346: 6.8 Statements from Primary Care Tr
Page 347 and 348: 6.8.4 Wiltshire Primary Care Trust
Page 349 and 350: 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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