Annual Report and Accounts - The Great Western Hospital

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The trust chose not to contribute to the repeat audit of National Health Promotion in Hospitals as the trust was compliant with the standards audited in the initial project and has other internal measures in place to monitor compliance. In addition the trust has now signed up to participate in severe trauma (Trauma Audit & Research Network). The Trust participated in a number of other National Audits during 2011-2012 that were considered vital in promoting the quality and effectiveness of patient care. A few of these are outlined below: Other National Clinical Audits National Cancer Patient Survey (as mandated by the National Cancer Reform Strategy) College of Emergency Medicine (CEM) - Fractured Neck of Femur's (NOF) in Emergency Department College of Emergency Medicine (CEM) - Asthma in Emergency Department CEM - National Audit of Emergency Department Discharge Data on GP Letters Inpatient Audit of Children with Diabetes (SWPDN) National Mastectomy and Breast Reconstruction Audit-(4th Round-Final) National Comparative Audit of the use of Red Cells in Neonates & Children National Diabetes Inpatient Day Audit Major Complications of Airway Management The national clinical audits and national confidential enquiries that Great Western Hospitals NHS Foundation Trust participated in, and for which data collection was completed during 2011/12, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Audit Title Peri-and Neo-natal Perinatal mortality (MBRRACE-UK) Submitted/Required (%) Ongoing internal review Neonatal intensive and special care (NNAP) 100% Children Paediatric pneumonia (British Thoracic Society) Ongoing- data submission deadline- Mar 2012 Paediatric asthma (British Thoracic Society) 100% Pain management (College of Emergency Medicine) 100% Childhood epilepsy (RCPH National Childhood Epilepsy Audit) 100% Diabetes (RCPH National Paediatric Diabetes Audit) 100% Acute care Emergency use of oxygen (British Thoracic Society) 100% Adult community acquired pneumonia (British Thoracic Society) Ongoing- data submission deadline- May 2012 Non invasive ventilation -adults (British Thoracic Society) Ongoing- data submission deadline- May 2012 Pleural procedures (British Thoracic Society) 100% Adult critical care (ICNARC CMPD) 100% Potential donor audit (NHS Blood & Transplant) 100% Page 91 of 211
Audit Title Submitted/Required (%) Long term conditions Heavy menstrual bleeding (RCOG National Audit of HMB) 100% Chronic pain (National Pain Audit) 100% Ulcerative colitis & Crohn's disease (UK IBD Audit) 100% Parkinson's disease (National Parkinson's Audit) 100% Adult asthma (British Thoracic Society) 100% Elective procedures Hip, knee and ankle replacements (National Joint Registry) 100% Elective surgery (National PROMs Programme) 100% Coronary angioplasty (NICOR Adult cardiac interventions audit) 100% Peripheral vascular surgery (VSGBI Vascular Surgery Database) 100% Carotid interventions (Carotid Intervention Audit) 100% Cardiovascular disease Acute Myocardial Infarction & other ACS (MINAP) 100% Heart failure (Heart Failure Audit) 100% Acute stroke (SINAP) 100% Cardiac arrhythmia (Cardiac Rhythm Management Audit) 100% Cancer Lung cancer (National Lung Cancer Audit) 100% Bowel cancer (National Bowel Cancer Audit Programme) 100% Head & neck cancer (DAHNO) 100% Oesophago-gastric cancer (National O-G Cancer Audit) 100% Trauma Hip fracture (National Hip Fracture Database) 100% Blood transfusion Bedside transfusion (National Comparative Audit of Blood 100% Transfusion) Medical use of blood (National Comparative Audit of Blood 100% Transfusion) End of life Care of dying in hospital (NCDAH) 100% The reports of 21 national clinical audits were reviewed by the provider in 2011/12 and Great Western Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided: - No. Audit Title 1. National Cancer Patient Survey 2. National Audit of Dementia 2010 3. National Mastectomy and Breast Learning From The Project Actions include- Focussed survey to assess service opportunities in Day therapy centre. Local survey was undertaken and the report is covered under “Local Audits”. The Trust performed in the middle quartile. The audit demonstrated a few areas of good practice. The action plan has been incorporated into the Trust Dementia Strategy. The Trust has signed up to participate in the next round of National Audit of Dementia. The Trust performance is in the upper 25% centiles in terms of satisfaction. The time that the clinical nurse specialists take with these patients needs to be recognised for future increase in caseload. The trust must continue to provide patients with Page 92 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
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CHART - Percentage of patients who
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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
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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 295 and 296: G.1.2 - The Board should clarify in
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Page 309 and 310: No. Audit Title Audit Summary/Learn
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Page 313 and 314: 6.3.4 Registration with Care Qualit
Page 315 and 316: Steering Group, provides a quarterl
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Page 321 and 322: Priority 3: To reduce harm associat
Page 323 and 324: Pressure ulcers Community: The comm
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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
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
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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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