Annual Report and Accounts - The Great Western Hospital

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GRAPH - Medicine incidents by type 2011/12 Medicine incident trends and types are reviewed as part of the work program of the Medicines Governance Group. The main incident type is missed doses, and this reflects the increased awareness around this issue. The number of missed doses is audited on a regular basis and there are workplans in place for several areas. All medicine related incidents were seen and reviewed by a Medicines Governance Pharmacist and assessed for severity and further investigated when necessary. Trends and reoccurring incidents were discussed at the Medicines Governance Group. This group was significantly changed in 2011/12. The membership was extended to include Wiltshire Community representation and also to widen the membership to all directorates and to include both senior and junior medical staff. The Medicines Governance Group also added membership from the training department to ensure safety messages were integrated as part of Trust training. During the year, the Pharmacy Medicines Governance Team produced a series of medicines safety bulletins to highlight particular issues within the Trust. Training was provided at induction to nursing and medical staff and this was modified to include learning from recent incidents and near misses. Further information about medicines management, notably the areas listed below, is included in the Trust’s Quality Account: - • Regional Quality Improvement Programme • Medicines security audits • Medical Gas Cylinder Management • Discharge information and improved patient medicine information. • Patient’s own medicine ‘Green Bag’ • Pharmacy Robot • Pharmacy Training • Clinical Pharmacy Services and Key Performance Indicators • Amalgamation with Wiltshire Community Health Service Units Page 109 of 211
Priority 3: To reduce harm associated with patient falls Harm from falls GWH: This year the Trust has focused on a 10% reduction in severe harm and death from falls in the acute setting, as categorised by the NPSA (National Patient Safety Agency) guidance. The figures indicate that the Trust’s performance exceeded the target by 32% for the year. The acute Trust has an implementation programme for rolling out a new falls care bundle to all adult wards by April 2012, supported by a training workbook. The care bundle named by the Trust as “SAFE” (Stratification and Avoidance of Falls in the Environment) is in line with the latest evidence based guidance on falls prevention in hospitals, as produced by the Royal College of Physicians in 2011. As part of the implementation programme there is a monitoring tool developed by April 2012 to audit compliance of the falls care bundle across the Trust. The focus going forward in 2012/13 will be to facilitate the acute wards to effectively implement this new care bundle, working towards 95% or greater compliance by November 2012. This aims to ensure we are providing the best possible standards of care for patient at risk of falls. GRAPH – Reduction of serious harm from falls GWH Reduction of serious harm for falls - GWH Total Target Total Achieved Total Numbers 30 25 20 15 Falls - WCHS Not possible to set a target for the reduction in numbers of falls resulting in severe harm/death, as there was not a robust system in place to record the level of harm from reported falls prior to 2011/12. Since merger in June 2011/12, 2 severe harm falls have been recorded and no deaths . 24 Total 22 Target of 24 or less Total Target of 22 or less 15 15 10 5 0 2010/11 2011/12 April 2010 to March 2012 Page 110 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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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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Page 271 and 272: 5.1.11 Council of Governors Meeting
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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 335 and 336: Priority 12: To undertake nutrition
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Page 339 and 340: Community: • Q1 Performance April
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Page 347 and 348: 6.8.4 Wiltshire Primary Care Trust
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Page 353 and 354: Graphs 3 and 4 show energy consumpt
Page 355 and 356: Graph 7 - Water consumption in WCHS
Page 357 and 358: 8 EQUALITY REPORTING 8.1 Equality d
Page 359 and 360: 9 STAFF SURVEY REPORT 9.1 Our staff
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Page 367 and 368: 10 REGULATORY RATINGS REPORT 10.1 M
Page 369 and 370: 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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